Employment Application

Rae-ann Skilled Nursing and Rehabilitation Centers Employment application

Desired Location

Personal Information

First Name

Middle Name

Last Name

Present Address

City

State

Zip Code

Daytime Phone

Evening Phone

Cell Phone

E-mail Address

Are you 18 years or older?    YesNo

Are you eligible for employment in the United States and can you prove identification and eligibility verification as required by U.S. Citizenship and immigration services?   YesNo

General Information

Position Desired

Shift Preference

DayAfternoonNight
8 Hour10 Hour12 Hour
Full TimePart Time

Foreign Languages Spoken  

Previously Applied to Rae-Ann?    

YesNo When?  

Previously Employed by Rae-Ann?    

YesNo When?  

Are you related to anyone at Rae-Ann?    
YesNo

Who/How  

Why do you choose nursing home work?

What prompted you to apply here?

Education

Name and Location of Schools or Colleges



Major Subject Studied



Did You Graduate?



Degree/Honors Received?



Grade Point Average



Professional License and/or registration? 
YesNo

License/Registration Number   State of Ohio?   YesNo

Date Issued  

Experiation Date

Work History

May we contact former employers for references?  YesNo

Name/Address/Phone Number



Nature of Experience



Period From / To



Hourly Wage/Salary



Reason for Leaving



Have you ever been terminated from employment for cause or been dishonorably discharged from the military?

YesNo
If Yes, Please Explain:


Answering "Yes" is not Necessarily a bar to employment. When making Decisions, the recency and job relatedness of any discharge will be considered.

Organizations

Please list memberships in any union, professional or trade organization.

Name





Address





Phone





Personal References (Not Relatives)

Name





Address





Phone





FCRA Disclosure and Authorization

I UNDERSTAND AND ACKNOWLEDGE THAT, AS PART OF THE COMPANY’S PROCEDURE FOR PROCESSING THIS EMPLOYMENT APPLICATION AND, IF HIRED, DURING MY EMPLOYMENT, THE COMPANY MAY, FROM TIME TO TIME, OBTAIN AN INVESTIGATIVE CONSUMER REPORT CONTAINING FINANCIAL AND OTHER INFORMATION ABOUT ME, INCLUDING INFORMATION ABOUT MY CHARACTER, GENERAL REPUTATION, PERSONAL CHARACTERISTICS AND MODE OF LIVING FROM A CREDIT REPORTING AGENCY. I UNDERSTAND AND ACKNOWLEDGE THAT THIS AUTHORIZATION IS CONTINUING IN NATURE AND THE COMPANY COMPLIES WITH THE FAIR CREDIT REPORTING ACT, WHICH PROVIDES CONSUMERS WITH RIGHTS REGARDING CONSUMER REPORTS AND WHICH PLACES SPECIFIC OBLIGATION ON EMPLOYERS USING CREDIT REPORTS. FURTHER, I AUTHORIZE THE COMPANY TO ORDER INVESTIGATIVE CONSUMER REPORTS CONTAINING FINANCIAL AND OTHER INFORMATION ABOUT ME, INCLUDING INFORMATION ABOUT MY CHARACTER, GENERAL REPUTATION, PERSONAL CHARACTERISTICS AN MODE OF LIVING, FROM A CREDIT REPORTING AGENCY AS PART OF THE COMPANY’S INVESTATION INTO MY APPLICATION FOR EMPLOYMENT AND AT ANY TIME DURING MY EMPLOYMENT, IF ANY, WITH THE COMPANY.

At-Will

I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS “AT-WILL” FOR NO DEFINATE PERIOD AND MAY, REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES, BE TERMINATED AT ANY TIME WITHOUT NOTICE AND/OR WITHOUT CAUSE.

Application

SHOULD A POSITION NOT BE IMMEDIATELY AVAILABLE, WE WILL KEEP YOUR APPLICATION ON FILE FOR 90 DAYS, AFTER WHICH TIME YOU WILL NEED TO REAPPLY.

Preliminary Questions:

HAVE YOU EVER BEEN CONVICTED OF, OR PLEADED GUILTY OR NO CONTEST TO, A FELONY OR A MISDEMEANOR INVOLVING ANY VIOLENT ACT, USE OR POSSESSION OF A WEAPON OR DRUGS, OR AN ACT OF DISHONESTY OR THEFT?

YesNo

IF YES, PLEASE EXPLAIN:

ARE YOU CURRENTLY OUT ON BAIL OR RELEASED ON YOUR OWN RECOGNIZANCE PENDING TRIAL?

YesNo

IF YES, PLEASE EXPLAIN:

CONVICTION OF A CRIME, UNLESS A DISQUALIFYING OFFENSE, IS NOT NECESSARILY A BAR TO EMPLOYMENT. WHEN MAKING THE HIRING DECISION, THE RECENCY AND JOB RELATEDNESS OF THE CONVICTION, AMONG OTHER FACTORS, WILL BE CONSIDERED BY THE COMPANY AS PERMITTED BY LAW. HAVE YOU BEEN A CONTINOUS RESIDENT OF OHIO FOR THE PAST FIVE YEARS?

YesNo

IF NO, PLEASE LIST ANY COUNTY AND STATE IN WHICH YOU RESIDED AND THE TIME PERIOD DURING WHICH YOU LIVED THERE:

Felony / Misdemeanor Disclosure

Have your ever been convicted of any of the following felonies and/or misdemeanors listed below?  


YesNo

3701-13-05 Disqualifying offenses

A. Except as provided in rule 3701-13-06 of the Administrative code, no DCP shall employ a person in a position that involves providing direct care to an adult if the person has been convicted of or pleaded guilty to:

1. A violation of any of the following sections of the Revised Code:

  • a) 2903.01-aggravated murder, specific intent to cause death
  • b) 2903.02-murder
  • c) 2903.03-voluntary manslaughter
  • d) 2903.04-involuntary manslaughter
  • e) 2903.11-felonious assault
  • f) 2903.12-aggravated assault
  • g) 2903.13-assault
  • h) 2903.16-failing to provide for a functionally impaired person
  • i) 2903.21- aggravated menacing
  • j) 2903.34-patient abuse or neglect
  • k) 2905.01-kidnapping
  • l) 2905.02-abduction
  • m) 2905.11-extortion
  • n) 2905.12-coercion
  • o) 2907.02-rape
  • p) 2907.03-sexual battery
  • q) 2907.05- gross sexual imposition
  • r) 2907.06-sexual imposition
  • s) 2907.07-importuning
  • t) 2907.08-voyeurism
  • u) 2907.09-public indecency
  • v) 2907.12-felonious sexual penetration
  • w) 2907.25-prostitution
  • x) 2907.31-dissemination matter harmful to juveniles
  • y) 2907.32-pandering obscenity
  • z) 2907.321-pandering obscenity involving a minor
  • aa) 2907.322-pandering sexually oriented matter involving a minor
  • bb) 2907.323-illegal use of a minor in nudity-oriented material or performance
  • cc) 2911.01-aggravated robbery
  • dd) 2911.02-robbery
  • ee) 2911.11-aggravated burglary
  • ff) 2911.12-burglary
  • gg) 2911.13-breaking and entering
  • hh) 2913.02-theft, aggravated theft
  • ii) 2913.03-unauthorized use of a vehicle
  • jj) 2913.04-unauthorized use of property, unauthorized access to computer systems
  • kk) 2913.11-passing bad checks
  • ll) 2913.21-misuse of credit cards
  • mm) 2913.31-forgery
  • nn) 2913.40-medical fraud
  • oo) 2913.43-securing writings by deception
  • pp) 2913.47-insurance fraud
  • qq) 2913.51-receiving stolen property
  • rr) 2919.25-domestic violence
  • ss) 2921.36-prohibition of conveyance of certain items onto grounds of detention facility or mental health or mental retardation and developmental disabilities facility.
  • tt) 2923.12-carrying concealed weapons
  • uu) 2923.13-having weapons while under disability
  • vv) 2923.161-improperly discharging firearm at or into habitation or school
  • ww) 2925.02-corrupting another with drugs
  • xx) 2925.03-trafficking offenses
  • yy) 2925.11-drug abuse: certain violations do not constitute criminal record
  • zz) 2925.13-permitting drug abuse
  • aaa) 2925.22-deception to obtain a dangerous drug
  • bbb) 2925.23-illegal processing drug document
  • ccc) 3716.11-adulteration of food, or

2. A violation of an existing or former law of this state, any other state or the United States that is substantially equivalent to any of the offenses or violations listed in paragraph (A) (1) of this rule.
B. Pardons. A conviction of or a plea of guilty to an offense listed or described in paragraph (A) of this rule shall not prevent an applicant’s employment under any of the following circumstances.
(1) The applicant has been granted an unconditional pardon for the offense pursuant to chapter 2967. of the Revised code.
(2) The applicant has been granted an unconditional pardon for the offense pursuant to an existing or former law of the state, any other state, or the United States, if the law is substantially equivalent to chapter 2967. of the Revised code.
(3) The conviction or guilty plea has been set aside pursuant to law: or
(4) The applicant has been granted a conditional pardon for the offense pursuant to chapter 2967. of the Revised Code, and, if an only if the conditions under which the pardon was granted have been satisfied.
I have fully disclosed any felonies or misdemeanors for which I have been convicted:


Signature    

Date


Criminal Background Check and Fingerprinting

OHIO LAW (ORC § 3721.121) REQUIRES ALL NURSING HOME EMPLOYEES, AND OTHERS WHO WORK WITH THE ELDERLY, TO BE FINGERPRINTED AND TO UNDERGO A CRIMINAL BACKGROUND CHECK. AS SUCH, YOU MUST:

  1. PROVIDE THE INFORMATION REQUESTED BELOW
  2. SUBMIT TO FINGERPRINTING
  3. CONSENT TO A CRIMINAL BACKGROUND CHECK

SHOULD YOU REFUSE, YOUR APPLICATION WILL NOT BE CONSIDERED, NOW OR IN THE FUTURE.

ANY EMPLOYMENT OR OFFER OF EMPLOYMENT IS CONDITIONAL ON A FAVORABLE CRIMINAL BACKGROUND CHECK. WE ARE REQUIRED BY STATE LAW TO DISCHARGE ANY EMPLOYEE IF RESULTS OF A CRIMINAL BACKGROUND CHECK ARE NOT OBTAINED WITHIN 30 DAYS AFTER THE CHECK IS REQUESTED, UNLESS THE REQUEST IS PENDING WITH THE FBI. AS WELL, WE ARE REQUIRED BY STATE LAW TO IMMEDIATELY TERMINATE ANY EMPLOYEE FOUND TO HAVE BEEN CONVICTED OR PLEADED GUILTY TO ANY OF THE DISQUALIFYING CHARGES LISTED BELOW.

Acknowledgement, Authorization and Attestation

I AUTHORIZE RAE-ANN NURSING FACILITIES AND ANY INVESTIGATING AGENCY TO PERFORM A CRIMINAL BACKGROUND CHECK IN CONNECTION WITH MY APPLICATION FOR EMPLOYMENT. I FOREVER RELEASE AND DISCHARGE RAE-ANN, THE INVESTIGATING AGENCY AND ANY OF THEIR RESPECTIVE OFFICERS, EMPLOYEES, AGENTS, INDEPENDENT CONTRACTORS, SUCCESSORS AND ASSIGNS FROM ANY CLAIMS, DAMAGES, LOSSES, LIABILITIES, COSTS AND EXPENSES RELATED TO GATHERING AND REPORTING INFORMATION PURSUANT TO THIS RELEASE AND FROM ANY CHARGE OR COMPLAINT FILED WITH ANY AGENCY RELATED TO OBTAINING AND/OR REPORTING ANY INFORMATION PURSUANT TO THIS RELEASE.

I ATTEST THAT THE INFORMATION PROVIDED IN CONNECTION WITH THE CRIMINAL BACKGROUND CHECK IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND I UNDERSTAND THAT, IF EMPLOYED OR OFFERED EMPLOYMENT, FALSIFIED STATEMENTS SHALL BE GROUNDS FOR DISMISSAL OR WITHDRAW OF SUCH OFFER OF EMPLOYMENT.


Signature:   

Date:


Upload Your Resume:

* RAE-ANN SKILLED NURSING AND REHABILITATION CENTER IS AN EQUAL OPPORTUNITY EMPLOYER