Education and Training
Most Recent Employer
Second Most Recent Employer
Third Most Recent Employer
Background Information and Consent
(A sex crime; exploitation of an endangered adult; failure to report battery; neglect, or exploitation of an endangered adult; murder; voluntary manslaughter; involuntary manslaughter [within the past 5 years]; felony battery [within the last 5 years]; a felony offense related to controlled substances [within the past 5 years]; theft [within the past 5 years]; abused, neglected, or mistrated a patient; misappropriated the property of a patient; or had a finding entered into the state nurse aid registry.)
This institution does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination. I voluntarily give this institution the right to make a thorough investigation of my past employment and activities. I agree to cooperate in such investigation and release from all liability or responsibility all persons, companies, or corporations supplying such information. I consent to take the pre-employment physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that my employment is 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 false statement or omission in face appearing on this application form. If employed, I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory evidence of identity and eligibility for employment.
This electronic signature will be seen as an official signature.