Application for Employment

Federal and State laws prohibit discrimination in employment because of sex, age, race, color, religious creed, marital status, national origin, ancestry, disability or other classification protected by State, Federal or local law. Autumn complies with these laws.

Facility *

Date

Personal Information

Last Name *

First Name *

Middle Name

Street Address

City

State

Zip Code

Contact Number

Date Available for Work

Alternate Contact Number

Email Address *

Social Security Number

Position Applying For

Are you legally authorized to work in the United States?

YesNo

Do you now, or will you in the future, require immigration sponsorship for work authorization (e.g., H-1B)?

YesNo

Are you under the age of 18?

YesNo

How were you referred to Employer?

Have you ever worked at this facility before?YesNo

Employment Desired

Employment Type

Full TimePart TimeTemporary

Shift Preference

DayEveningNight

Days Available to Work

SunMonTuesWedThursFriSat

Are you able to perform the essential functions of the job for which you are applying?YesNo

Do you have any pending or actual disciplinary actions against your license?YesNo

Personal References

List three professional or personal references not related to you (other than current/former supervisors).

Name

Telephone No.

E-mail Address

Type of Acquaintance

Name

Telephone No.

E-mail Address

Type of Acquaintance

Name

Telephone No.

E-mail Address

Type of Acquaintance

Certifications & Licenses

Type of License/Certification #1

Number

State

Expiration

Type of License/Certification #2

Number

State

Expiration

Additional certifications or licenses you currently possess

Please comment on how your prior education and experiences qualify you for this position

Education

Type of School	School Name & Location	Highest Grade Completed	GPA	Course of Study / Major
High School / G.E.D.			N/A
College / University
Vocational / Trade School
Graduate School
Other (incl. military)

Employment History

List ALL work experience starting with your most recent employer for the past three years.

Current/Most Recent Employer

Current Employer

Phone

Geographic Location

From (Month/Year)

To (Month/Year)

Your Position

Supervisor's Name/Title

Primary Responsibilities

Reason for Leaving

May we contact?YesNo

Employer #2

Employer

Phone

Geographic Location

From (Month/Year)

To (Month/Year)

Your Position

Supervisor's Name/Title

Primary Responsibilities

Reason for Leaving

May we contact?YesNo

Employer #3

Employer

Phone

Geographic Location

From (Month/Year)

To (Month/Year)

Your Position

Supervisor's Name/Title

Primary Responsibilities

Reason for Leaving

May we contact?YesNo

Employer #4

Employer

Phone

Geographic Location

From (Month/Year)

To (Month/Year)

Your Position

Supervisor's Name/Title

Primary Responsibilities

Reason for Leaving

May we contact?YesNo

Please account for any gaps of employment

Additional Comments

Background Information

1. During the past seven years, have you ever been discharged, suspended or asked to resign from any position?

YesNo

2. Have you ever been convicted of a crime (such as homicide, assault, kidnapping, sexual offenses, robbery, and crimes against the family, children or incompetents)? (A conviction record will not necessarily be a bar to employment)

YesNo

Compliance Questionnaire

Pursuant to Federal law and the Office of the Inspector General's (OIG) recommendations, each applicant must answer and certify the following:

1. Have you ever had your professional license suspended or revoked? If yes, in which State(s) and when?

YesNo

2. Are you currently charged with a criminal offense related to the delivery of health care services or have you been charged with any offense(s) that are identified by the Department of Health as prohibiting an individual from working in this field?

YesNo

3. Have you ever been convicted of a felony or misdemeanor (including a plea bargain or other arrangement with prosecuting authorities) relating to the delivery of health care services and/or the crimes of neglect, violence, theft, dishonesty, or financial misconduct?

YesNo

4. Have you ever been excluded (or proposed for exclusion) from the Medicare or Medicaid programs or any other federally funded health program, or had a civil monetary penalty or administrative fine imposed against you?

YesNo

5. Have you ever been listed on the publication for the Treasury's Office of Foreign Assets Control ("OFAC")?

YesNo

I hereby certify that I am not currently charged with a criminal offense related to the delivery of health care services, have never been convicted of an offense that would preclude my employment at a nursing facility and that I have not been excluded from participation in the Federal health care programs.

Please Read Carefully and Initial Each Paragraph

I have disclosed all information that is relevant and should be considered applicable to my candidacy for employment.

I understand, where permissible under applicable state and local law, I may be subject to a pre-employment drug test and/or medical examination after receiving a conditional offer of employment, and must receive a negative result for illegal drugs and meet the qualifications for the position, with or without reasonable accommodation, before being permitted to commence work with Autumn.

I hereby certify that the information given by me is true in all respects. I authorize Autumn and its representatives to contact my prior employers and all others for the purpose of verification of the information I have supplied and release same from any liability resulting from the information released.

I understand employment with Autumn is contingent on my providing sufficient documentation necessary to establish my identity and eligibility to work in the United States, and upon maintaining the proper licensure or certification necessary for my position.

I certify, under penalty of perjury, that all of the above information is true and complete, and I understand that any falsification, misrepresentation or omission of information may result in denial of employment or, if hired, may result in termination regardless of the time lapse before discovery.

I understand that no representation, whether oral or written, by any representative or agent of Autumn at any time, can constitute an implied or expressed contract of employment. I understand and agree that if employed, my employment, having no specified term, is based upon mutual consent and may be terminated at will, with or without cause, by either party without prior notice. I understand that any employment by Autumn will entail an initial introductory period, and that Autumn may change benefits, policies and conditions of employment at any time.

I certify that the answers and information provided herein are true and complete to the best of my knowledge.
MY SIGNATURE IS EVIDENCE THAT I HAVE READ AND AGREE WITH THE ABOVE STATEMENTS.

Applicant's Name (Print Full Name) *

Date *

Applicant's Signature *

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