Employment Application Form Application for Employment Contact InformationName* First Last Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code TelephoneCell PhoneMinor InformationStanton Health Center does not hire anyone under the age of 16. Nursing and maintenance personnel must be at least 18 years of age. Transportation personnel must be at least 25 years of age.If under 18, date of birth: If you are under the age of 18, and it is required, can you furnish a work permit?YesNoWork InformationDate available for work:* Desired Salary:Required InformationHave you been accused or found guilty of abuse, neglect, or misappropriation of property of any person?*YesNoAre you currently under any type of investigation by the licensure division of the Department of Health & Human Services or any other licensure/certification body?*YesNoIf yes, explain.*Have you ever had a state license/certification to practice revoked, suspended, denied, restricted, limited, or issued/placed on a probationary status or voluntarily relinquished?*YesNoHave you ever plead “guilty” or “no contest” to, or been convicted of a crime?*Answering “yes” to the preceding question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation, and position applied for will be taken into account. YesNoIf yes, specify dates & details:*Do you have any criminal charges waiting to be heard by a court of law?*Answering “yes” to the preceding question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation, and position applied for will be taken into account. YesNoIf yes, explain:*Are you listed on the Child or Adult Abuse Registry?*YesNoAre you listed on the Sex Offender registry?*YesNoAre you listed on the Office of the Inspector General’s Exclusion List?*YesNoAre you listed on the General Services Administration’s List of Parties Excluded from Federal Procurement and Non—procurement Programs?*YesNoAre you listed on the Nebraska Medicaid Excluded Provider’s Database?*YesNoAre you legally eligible for employment in this country?*YesNoHave you ever been employed here before?*YesNoEmployment date(s)*Position(s)*Reason for leaving:*Do you have any relative that works here?*YesNoIf yes, please list name(s) & relationship(s):*Educational BackgroundList most recentSchool 1Including City & StateCompleted 1DiplomaGEDDegreeCertificationMajor/Minor 1If applicable.School 2Including City & StateCompleted 2DiplomaGEDDegreeCertificationMajor/Minor 2If applicable.Employment History Starting with your most recent employer.ReferencesIndividuals that we can call for a reference. Do not list family members.Applicant’s StatementI certify that all the information I have provided in order to apply for and secure work with this employer is true, complete, and correct. I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees, or representatives, for seeking, gathering, and using truthful and nondefamatory information, in a lawful manner, in the employment process and all the other persons, corporations, or organizations for furnishing such information about me. I understand this application remains current for only 30 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application. I understand that in order to be eligible for employment at Stanton Health Center, I must not be listed on HHS-OIG’s List of Excluded Individuals and Entities, the General Services Administration’s List of Parties Excluded from Federal Procurement and Non-procurement Programs, or the Nebraska Medicaid Excluded Provider’s Database. I understand that this application is not a contract of employment. I also acknowledge that no oral representations have been made, and that no one has the authority to make oral contracts of employment. If hired, my employment relationship is terminable at-will, with or without cause, by either myself or the Employer. No implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the employer’s president. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard. I understand that this employer uses E-Verify and will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Security (DHS), with information from each new employee’s I-9 Form to confirm work authorization. I also understand that if there are any adverse findings on the criminal background check, adult registry of abuse and neglect, child abuse registry of abuse and neglect, or the sex offender registry, the facility may choose to terminate employment. I understand that if any adverse findings are found on the Nurse or Nurse Aide Registry, the facility CANNOT employ me. Applicants are not obligated to disclose any sealed criminal record. I understand that any information provided by me that is found to be false, incomplete, or misrepresented, at any time, in any respect, will be sufficient cause to: Eliminate me from further consideration for employment, or May result in my immediate discharge from the employer’s service.DO NOT SUBMIT APPLICATION UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT! I CERTIFY THE FOLLOWING:* I have read, fully understand and accept all terms of the foregoing applicant statement I CERTIFY THE FOLLOWING:* I have not been subject to sanctions or exclusions under the Medicare or Medicaid Programs and have not been convicted of violation of other laws other than those I listed on the first page of the application. NameThis field is for validation purposes and should be left unchanged. Δ This iframe contains the logic required to handle Ajax powered Gravity Forms.