APPLICANT
Acknowledgment and disclaimer


The information that I will provide on my application of employment with the Company is true and complete to the best of my knowledge. Any misrepresentation or omission of fact in my application, resume, or other materials, or during any interviews, can be justification of refusal or employment, or if employed, termination from the Company's employ.

I authorize and request that all of my former employers and those individuals I list as personal references on my application of employment furnish information about my employment record, including a statement of the reason for the termination of my employment, work performance, abilities, and other qualities pertinent to my qualifications for employment.

I understand that if I am employed by the Company, the Company may inform me or I may become aware of policies and procedures that the Company may issue and adopt from time to time. I understand that such policies and procedures are guidelines which may be changed or withdrawn by the Company for any reason and at any time without notice. I understand that these policies and procedures, separately or taken as a whole, do not create a contract, express or implied, between me and the Company.

I further understand that should I become employed by the Company, I understand that my employment may be terminated with or without cause or notice, at any time, at the option of either the Company, or myself. I further understand that no manager or representative of the company, other than the President has any authority to enter into any agreement with me for employment for any specified period of time or to make any agreement different from or contrary to the statements set forth above. I also understand that any such agreement, if made, shall not be enforceable unless it is in writing and signed by me and the President of the Company.

I further understand that should I become employed by the Company, I understand that my employment may be terminated with or without cause or notice, at any time, at the option  of either the Company, or myself. I further understand that no manager or representative of the company, other than the President has any authority to enter into any agreement with me for employment for any specified period of time or to make any agreement different from  or contrary to the statements set forth above. I also understand that any such agreement, if  made, shall not be enforceable unless it is in writing and signed by me and the President  of  the Company.


Uniform Employment Application

This application form is required by Title 63 O.S. § 1-1950.4 of state law and by the Oklahoma State Board of Health Rules OAC 310-2-15-3. This uniform application shall be used as the only application for employment of nurse aides in nursing and specialized nursing facilities, residential care homes, assisted living centers, continuum of care facilities, hospice programs, adult day care centers and home care agencies.

This employer does not discriminate in its hiring decisions or in any other employment decision on the basis of race, color, sex, religion, citizenship, national origin, veteran status, age or upon a physical or mental disability which is unrelated to the applicant's/employee's ability to perform the essential functions of the position.

Date of Application
Date Available to Start Work

Personal Information

Other names

List any other name(s) you have previously worked under, such as maiden name:

Present Address

Permanent Address (if different than present address):

Contact Information

[-------------------------- For purposes of Criminal History Records Search --------------------------]

Emergency Contact Person

Employment Desired

Hours available to work:

Will you accept employment of:

Military record

Prior Work History

List your last four (4) jobs beginning with your most recent or current employer.

Date Employed From

To

Date Employed From

To

Date Employed From

To

Date Employed From

To

List name(s) of all other employers for the last five (5) years:

May we contact your present employer?

Have you ever been terminated or asked to resign from any position?

Educational Background

Name of Institution (High School, Technical School, College) Type of Studies Dates Attended & Diplomas, etc.

If your school or employment records are under another name(s), indicate that name(s)

Certifications

If you hold a current certification as a nurse aide (CNA), check the appropriate certification(s) below:

List all technical special skills or education honors, certificates, licenses, memberships or Medication Administration Technician (MAT) certification not previously listed:

If you are a CMA, have you obtained your 8 hours of continuing education for the current 12-month certification period before your certification expires?

If yes, where and when did you obtain.

References

Background Information

If you answer YES to any of the questions below, explain in the space after the question.
The explanation for a YES answer should include, but not be limited to:

  1. State and/or jurisdiction.
  2. Nature of complaint/offense.
  3. Disposition of complaint and/or offense (e.g., "dismissed insufficient evidence", "deferred sentence").
  4. Date of disposition.
  5. Attach copy of any correspondence received by you, the applicant, regarding the complaint/offense.

Have you ever 1) participated in a first offender program; 2) deferred adjudication or other program or arrangement where adjudication has been withheld; 3) pled guilty or no contest; 4) been convicted; 5) received a deferred sentence; and/or 6) been sentenced for any criminal offense in any state or US jurisdiction regardless of whether this matter has been expunged or otherwise removed?

Have you ever been found in violation of any state, US jurisdiction, or federal law regulating the practice of a health care profession?

Are any disciplinary actions or allegations. pending or substantiated, against you or your CNA certification or health care professional license in any state or U.S. jurisdiction?

Have you had any certificate, license, registration or other privilege to practice a health care profession denied, revoked, suspended, restricted, reprimanded, censured or placed on probation by a state or US jurisdiction, federal or foreign authority or have you ever surrendered such credential to avoid, or in connection with, action by such authority?

Applicant's Certification and Agreement

Please Read Carefully - If you answer 'No' to any of the questions below, explain in the space after the question.

I understand the employer has the right to proceed with any criminal background check.

I understand as a part of the job selection process, [ may be required to take a drug-screening test at the time of employment and if requested in accordance with the state and federal law at anytime during my employment. A test result that has been confirmed as positive will eliminate me from employment. Ifl refuse to sign this form and submit to drug testing, the employer will reject my application.

I understand I may be required to have a physical examination and I hereby consent to take a physical examination and any future physical examinations as required by the employer.

I understand if l am hired I will be required to produce proof that I have a legal right to work in the U.S.A. in accordance with the IRCA of 1986.

I understand this form is not an employment contract.

Previous CNA Training

Important Information

It is unlawful for any person to provide false information regarding a criminal conviction on this uniform employment application for nurse aides. Providing false information regarding a criminal conviction is a misdemeanor under Title 63 of the Oklahoma Statutes, Section t-t 950.4a. Providing false information about a criminal conviction on this application is punishable by a fine not to exceed Five Hundred Dollars ($500.00), by imprisonment in the county jail for a term of not more than one ( 1) year, or by both such fine and imprisonment.

I UNDERSTAND PROVIDING FALSE OR MISLEADING INFORMATION TO A TRAINING PROGRAM, A FACILITY, OR THE DEPARTMENT IS GROUNDS FOR DENIAL, SUSPENSION, WITHDRAWAL, AND/OR NONRENEWAL OF CERTIFICATION. I ALSO UNDERSTAND PROVIDING FALSE INFORMATION OR OMISSION OF FACTS MAY DISQUALIFY ME FROM EMPLOYMENT AND MAY CAUSE TERMINATION IF DISCOVERED AT A LATER DATE.

Criminal Arrest Check List

Effective November 1, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section 1-1950.l, employment at this employer shall not be considered if the below signed individual has been convicted of. pled guilty or no contest to, or received a deferred sentence/or, a felony or misdemeanor offense/or any of the following offenses in any state or federal jurisdiction, as stated by Oklahoma Statute, Section 1-1950. l(C)(l) of Title 63:

a. abuse, neglect or financial exploitation of any person entrusted to the care or possession of such person,
b. rape, incest or sodomy,
c. child abuse,
d. murder or attempted murder,
e. manslaughter,
f. kidnapping,
g. aggravated assault and battery,
h. assault and battery with a dangerous weapon, or
i. arson in the first degree.

Effective November 1, 2012, and in accordance with public law, Title 63 of the Oklahoma Statutes, Section 1-1950.1, employment at this employer shall not be considered for the below signed individual if less than seven (7) years have elapsed since the completion of sentence1, and the results of a criminal history check reveal that the subject person has been convicted of, or pled guilty or no contest to, a felony or misdemeanor offense for any of the following offenses, in any state or federal jurisdiction, as stated by Oklahoma Statute, Section 1-1950. l{C)(2) of Title 63:

a. assault,
b. battery,
c. indecent exposure and indecent exhibition, except where such offense disqualifies the applicant as a registered sex offender,
d. pandering,
e. burglary in the first or second degree,
f. robbery in the first or second degree,
g. robbery or attempted robbery with a dangerous weapon, or imitation firearm,
h. arson in the second degree,
i. unlawful manufacture, distribution, prescription, or dispensing of a Schedule I through V drug as defined by the Uniform Controlled Dangerous Substances Act,
J. grand larceny, or
k. petit larceny or shoplifting.

1 Pursuant to 63 O.S. § 1-1950.1 (A)(S), "Completion of the sentence" means the last day of the entire term of the incarceration imposed by the sentence including any term that is deferred, suspended or subject to parole.

It is further understood that if I am hired, it will be as a temporary employee until the employer receives my criminal background check. If I have no criminal record in accordance with state law, I may be considered for employment, subject to training requirements and other requirements of the job for which I am applying with this employer.

I hereby certify I have no disqualifications for employment as described above and specified in Title 63 of the Oklahoma Statutes, Section 1-1950.l(C). My signature below authorizes the employer to run a check with the Nurse Aide Registry of the Oklahoma State Department of Health for notations of abuse, neglect or misappropriation of resident's property. I hereby give the Oklahoma State Bureau of Investigation authority to proceed with a criminal history records check as authorized by Title 63 of the Oklahoma Statutes, Section 1- 1950.l(B).