Please list the names of three persons not related to you and whom you have known at least one year.
PLEASE READ THIS SECTION BEFORE SIGNING!
FALSIFICATION OF RECORDS
I completed this application and I certify that the information in this application is correct to the best of my knowledge. I understand that falsification of this application or omission of requested information in any detail is grounds for disqualification from further consideration or for dismissal from employment.
EMPLOYMENT AT WILL
I will follow the rules and regulations of the Louisville Care Community as communicated to me. I understand that in no event shall my hiring be considered as creating a contractual relationship between myself and the Louisville Care Community. Unless otherwise provided in writing, the employment relationship shall be defined as “employment at will,” and either party may dissolve the relationship without cause. I further understand that no employee or supervisor, except the Administrator or designee, has the authority to enter into any agreement or contract of employment for any specific terms of employment such as length of service, future salary increases or agreement contrary to this application. Furthermore, I understand that any such agreement entered into by the Administrator or designee will not be enforceable unless it is in writing.
CONDITIONAL OFFER OF EMPLOYMENT
If I receive a conditional offer of employment, I understand that I may be the subject of drug screening, criminal background study and/or physical screening and evaluation. I hereby consent to such screening and record checks.
PROOF OF RIGHT TO WORK
If I am offered a position with this center, I understand that as a condition of employment I will be required to prove identity and right to work as required by the Immigration Reform and Control Act of 1986.
PARTICIPATION IN GOVERNMENT PROGRAMS
I agree to inform my supervisor or Administrator if I become subject to exclusion from any Federal or State Health Care Program [as defined by 42 U.S.C. 1320a-7] as a vendor, provider or employee or contractor of a participating provider or if I become aware that I may be subject to such exclusion.
RELEASE OF INFORMATION
I acknowledge that consideration for employment is contingent on the results of a reference and background check. Therefore, I hereby authorize the Louisville Care Community to (1) investigate the truthfulness of all statements made on this application; (2) contact my former employers and other listed references or any other persons who can verify information; and (3) discuss the results of any investigation with other employees of the Louisville Care Community involved in the hiring process. In addition, I give my consent for all contacted persons, including former employers, to provide information concerning this application, and I release each such person from liability for providing information to the Louisville Care Community.
FAIR TREATMENT PROGRAM
As a term and condition of my employment, and unless covered by an individual employment contract or a collective bargaining agreement with different dispute resolution provisions, I agree to waive my right to a jury trial in any action or proceeding related to my employment with the Louisville Care Community. I am doing so voluntarily and knowingly. I understand that I have the right to consult with counsel before signing this document. I agree that all claims and disputes relating to my employment with the Louisville Care Center shall be decided by a mediator or arbitrator selected in accordance with the rules and procedures established by the national Arbitration Forum.
AMERICANS DISABILITIES ACT
Federal law obligates us to provide a reasonable accommodation to the known disabilities of applicants and employees, unless to do so would pose an undue hardship. Please feel free to let us know if you need an accommodation to complete the application process or to perform any essential elements of the position sought.
AFFIRMATIVE ACTION SURVEY FOR APPLICANTS
Louisville Care Community is a government contractor, subject to governmental regulations and affirmative action responsibilities. Applicants are considered for positions for which they apply and employees are treated during employment without regard to race; color; sex; national origin; age; disability; or status as Vietnam-era veteran, special disabled veteran and veteran who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized; or any other protected class.
To assist with required recordkeeping, reporting and other legal requirements please fill out this confidential survey. Providing this information is voluntary and refusal to provide this information will in no way affect your status as an applicant. This survey will be kept in a separate confidential file and will be used only for governmental reporting purposes.