Application for Employment

It is the policy of Citizens Care and Rehabilitation Center to recruit, hire, train, compensate, promote and provide other conditions of employment without regard to a person’s race, color, religion, sex (including pregnancy), national origin, age, sexual orientation, disability, genetic information, veteran status or other characteristic protected by law.

All Fields Are Required

Date: 04/20/2019

Personal Information

First Name Last Name

Address

City State Zip Code

Home Phone Cell Phone

Preferred Phone Number E-Mail Address

Are you 18 years of age or older?

Are you authorized to work in the United States?

(You will be required to show original acceptable documents and complete an Employment Eligibility Verification form (Federal I-9 form).

Referred by: Select One:

Emergency Contact Name Emergency Contact Relationship

Emergency Contact Phone #

Employment Desired

Position Employment Type

Available to Work: (Check all that apply)

Days Evenings Nights Weekends

Date you can start Desired Wages

Have you ever applied to Citizens? Have you ever been employed by Citizens?

If yes, what was your reason for leaving?

Education

Type	Name	Location	Course/Degree
High School
GED
College
Other

Training

Type	Issued By	Certificate/License #	Expiration Date
Nursing
	RN LPN GNA
CPR
Other

Employment History

List all employment, starting with your present or most-recent employer. Please give complete addresses.

Employer

Position Employment From Employment To

Street Address

City State Zip Code

Phone

Reason for Leaving

Employer

Position Employment From Employment To

Street Address

City State Zip Code

Phone

Reason for Leaving

Employer

Position Employment From Employment To

Street Address

City State Zip Code

Phone

Reason for Leaving

Personal or Professional References

Name/Capacity Known	Address/Phone Number	Years Known

Additional Information

Please provide any additional information (including volunteer experience) that you feel may be helpful to us in considering your application.

Convictions

Under Maryland law, a background check will be conducted.

Have you ever been convicted of, or have you pled guilty or no contest (nolo contendere) to a felony or misdemeanor offense?

Yes

If Yes, Provide dates, place of conviction, charge and disposition of each case. This information will not necessarily bar you from consideration for employment.

Employment Eligibility

The Immigration Reform and Control Act of 1986 prohibits the employment of unauthorized aliens, and employers are required to verify the employment eligibility of all new employees. An offer of employment with Citizens Care and Rehabilitation Center will be made conditional based on your providing the documentation required by law as evidence of your personal identity and your authorization to work in the United States.

Polygraph Disclaimer

Under Maryland law, an employer may not require or demand, as a condition of employment, prospective employment, or continued employment, that an individual submit to or take a lie detector or similar test. An employer who violates this law is guilty of a misdemeanor and subject to a fine not exceeding $100.

Employee Release and Privacy Statement

Please read carefully before signing.

Under Maryland law, I understand that Citizens Care and Rehabilitation Center is required to conduct a background check and request a reference from my most recent employer which shall, at minimum, inquire about any history of physical abuse. Therefore, I authorize Citizens Care and Rehabilitation Center to investigate my past employment, educational credentials and other employee-related information. I agree to cooperate in such investigations, and release those parties supplying such information to Citizens from all liability or responsibility with respect to information supplied.

I agree that Citizens Care and Rehabilitation Center may use the information it obtains concerning me in the conduct of its business, I understand that such use may include disclosure outside Citizens Care and Rehabilitation Center in those cases where its agents and contractors need such information to perform their functions, where Citizens’ legal interests and/or obligations are involved, or where there is a medical emergency involving me. I understand, however, that Citizens intends to protect the confidentiality of personal information it obtains concerning me. Consequently, personal information in Citizens record keeping systems, other than the fact and location of past or present Citizens employment, the dates of employment, or the job name and description of general duties, will not otherwise be disclosed outside Citizens with a personal identifier without my consent. Further, Citizens will require its agents and contractors to safeguard information disclosed to them by Citizens.

I understand that my employment with Citizens would not be for any fixed period of time and that, if employed, I may resign at any time for any reason or Citizens may terminate my employment at any time for any reason in the absence of a specific written agreement to the contrary.

I understand that any false answers or statements made by me on this application or supplement thereto or in connection with the above-mentioned investigation will be sufficient grounds for immediate discharge, if I am employed.

Applicant's Signature

Kind Words

Dear Citizens: From the Carrick family, we would like to say thank you. Mom was taken care of by very special people.

Carrick family