Hospice of Saint John -

CAREFULLY READTHIS SECTION PRIOR TO SUBMITTING BELOW

I understand that my employment can be terminated at any time with or without cause, at the option of either the facility or me. I understand that no one has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing, except for a written employment agreement signed by the President/CEO of this facility.

I understand if I work in a position that involves Medicare and/or Medicaid, and it is identified that I was convicted of Medicare/Medicaid fraud, this is just cause for immediate termination.

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.

I hereby authorize persons, schools, my current employer (if applicable), Law Enforcement and previous employers and organizations named in this application (and accompanying resume, if any) to provide this facility and all affiliates with any relevant information regarding an employment decision, and I release all such persons from any liability regarding the provision or use of such information.

All job offers are contingent upon the review of references, background checks, OIG Excluded Providers, pre-employment drug screening and other relevant information. Any misleading or incorrect statements, omissions or failure to disclose any health care related criminal conviction or any threatened or actual debarment, exclusion or other ineligibility of participation in federal funded health care programs may remove this application from further consideration for employment and, if employed, may be cause for termination. I therefore authorize The Hospice of Saint John Foundation, Inc. to complete a criminal reference and any other established pre employment testing.

Applicants Disclosure and Authorization for Background Screening
Other Names(s) Used: (like Maiden)
Date of Birth
Drivers License Number
	State
Place of Birth (City, State, County)
Gender
Former Addresses
Former Address 1
City		State
		Zip Code
Former Address 2
City		State
		Zip Code

* This information will be used for purposes of background screening only and will not be used in making any employment decisions.

DISCLOSURE AND AUTHORIZATION

NOTICE REGARDING BACKGROUND INVESTIGATION

Employer (“the Company”) may obtain information about you from a consumer reporting agency for employment purposes. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living, and which can involve personal interviews with sources such as your neighbors, friends, or associates, including motor vehicle record (or “driving record”) checks, workers compensation records, credit bureau files, employment references, personal references, drug screening, any educational and licensing institution or military branch and to receive any criminal record information pertaining to you which may be in the files of any Federal, State or Local criminal justice agency in Georgia or any other State. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by InfoMart, 1582 Terrell Mill Road, Marietta, GA 30067, 800-800-3774 or another outside organization. The scope of this notice and authorization is all-encompassing, however, allowing Employer to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and, if you are hired, throughout the course of your employment to the extent permitted by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of any investigative consumer report.

New York and Maine Applicants or Employees Only:You have the right to inspect and receive a copy of any investigative consumer report requested by Employer by contacting the consumer reporting agency identified above directly.

ACKNOWLEDGEMENT AND AUTHORIZATION

I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” at any time after receipt of this authorization and, if I am hired, throughout my employment. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by [the consumer reporting agency] , another outside organization acting on behalf of Employer, and/or Employer itself. I agree that a facsimile (“fax”) or photographic copy of this Authorization shall be as valid as the original.

New York Applicants or Employees Only:By submitting this form, you also acknowledge receipt of Article 23-A of the New York Correction Law.

Minnesota or Oklahoma Applicants or Employees Only:Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Company.

California Applicants or Employees Only:By submitting below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. Please check this box if you would like to receive a copy of an investigative consumer report or consumer credit report if one is obtained by the Company at no charge whenever you have a right to receive such a copy under California law.