Conviction of a criminal offense will not necessarily preclude you from employment, depending on the offense, level of severity, years since conviction, whether or not the offense disqualifies you for the employment in long term care under state regulations, federal regulations, and/or facility policy, and other considerations regarding the protection of facility residents against abuse, neglect, exploitation and misappropriation of property, as well as what is deemed by the Administration to be in the best interest of the safety and well-being of facility residents and others.

Please list the type of license or certification, what organization or State issued it, the date it was issued, the license or certificate number, and whether of not it is in good standing.

This facility does not discriminate in hiring or any other decision on the basis of race, color, age, sex, religion, national origin, disability, or veteran status except in specific situations where such discrimination is required in order to comply with statutory objectives. Language assistance services are available free of charge to individuals with limited English proficiency and reasonable accommodations are provided when possible. No question on this application is intended to secure information to be used for such discriminatory purposes.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigations and release from all liability or responsibility all people, companies, or corporations supplying such information. I consent to any inquired drug screening and/or physical examinations and such future screenings and physical examinations as may be required by this facility at such times and places as the facility shall designate. I understand that an offer of employment may be contingent on passing any required drug screens and/or physical examinations which relate to the essential duties I would be required to perform.

I understand that if I am offered employment, my employment will be at will, and that either party is free to terminate the employment relationship at any time with or without cause. I also understand that my employment may be terminated for any falsification, misstatement, or omission of fact discovered at any time to be appearing on this application form.

If employed, I understand that I will be required to complete an Employment Verification Form (I-9) during orientation, providing acceptable original documents serving as evidence of identity and eligibility to work in the United States.