List all employment history, most recent first.
Please list three references.
I acknowledge that the information I have furnished is correct to the best of my knowledge and understand that misstatement or omission of this information could be grounds for disciplinary action to include retraction of employment offer or dismissal, if employment has taken place.
I authorize this facility to contact any and/or all of my references for full information, and authorize you to check my local, state, and/or national police record, including fingerprints,at any time. As a condition of employment or continuation of employment, I agree to immediately report to the Home’s administration if I am arrested or convicted for any of the following offenses: any felony or attempted felony, or these misdemeanors--- abuse, neglect, assault, battery, criminal sexual conduct, fraud/theft against a vulnerable adult, or the possession or delivery of a controlled substance.
AN INDIVIDUAL WHO KNOWINGLY PROVIDES FALSE INFORMATION REGARDING CRIMINAL CONVICTIONS ON A STATEMENT FOR CONDITIONAL EMPLOYMENT OR CLINICAL PRIVILEGES IS GUILTY OF A MISDEMEANOR PUNISHABLE BY IMPRISONMENT FOR NOT MORE THAN 90 DAYS OR A FINE OF NOT MORE THAN $500.00 OR BOTH.
I agree to take a physical examination and/ or drug testing at any time, at the request of this facility and I agree that the examining physician may disclose the findings to this facility or an authorized agent of this facility.