Employment Application

Personal Info
First Name*
Middle Initial
Last Name*
Hidden
Date
MM slash DD slash YYYY
Phone*
Email*
Social Security Number*
Driver’s License Number*
State where Driver’s License Issued*
Date of Birth (for identification purposes only)*
My prospective employer understands that age is a protected characteristic and that any age related information requested will not be used as the basis for any employment decision.
MM slash DD slash YYYY
Present Address
Address*
Address 2
City*
State*
Country
ZIP*
Previous Address

Please provide any previous addresses you’ve resided at in the past 7 years.
Address
Address 2
City
State
Country
ZIP
Other names by which you have been known
Are you a U.S. citizen?*
- Yes
- No
Are you authorized to work in the U.S.?*
- Yes
- No
Have you ever been convicted of a felony or misdemeanor?*
- Yes
- No
When?*
MM slash DD slash YYYY
Explain the felony or misdemeanor
Position desired
Date Available
MM slash DD slash YYYY
Desired Salary

References

Please enter personal or professional references (non-relatives).
Name
First Name Last Name
Phone 1
Phone 2
Occupation

Work Experience

Please enter your work experience.
Work Experience #1
Company Name
Company Address
Company City
Company State
Company ZIP
Company Phone
When did you start?
When did you leave?
What was your position at this company?
Who was your supervisor?
What was your starting salary?
What was your salary when you left?
Why did you leave?
May we contact your present employer?
- Yes
- No
Explain

*
I understand that my information may be shared with Cardinal Learner and the Office of the Inspector General.

Fair Credit Reporting Act Disclosure
In conjunction with my application for new or continuing employment (including contract and/or volunteer services) with you, I understand that you intend to hire Selection Management Systems, Inc. (“SMS”) to obtain Consumer Reports and/or Investigative Consumer Reports (“Reports”) about me as defined in the federal Fair Credit Reporting Act (“FCRA”). These Reports may include information concerning my academic background, character, credentials, credit capacity, credit standing, creditworthiness, general reputation, mode of living, personal characteristics, reasons for work termination, work experience, work habits and/or work performance. You may also seek information concerning my civil litigation history, criminal record, educational background, employment history, motor vehicle record, and/or worker’s compensation history. I understand that you may rely on the information contained in these Reports in determining whether to extend an offer of employment to me or maintain my employment with you. I also understand that you may run Reports about me at least once every two years. If you contemplate making an adverse employment-related decision that will affect me based, in whole or in part, upon a Report obtained from SMS, I will receive a copy of the Report and a written summary of my Consumer Rights under the FCRA before you finalize that decision. I have read the above disclosure and I hereby authorize you, SMS or its authorized agents to obtain the above-referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above-referenced knowledge or information they have concerning me. This authorization shall remain on file and be valid for the duration of my employment with you. It shall serve as an ongoing authorization for you to obtain Reports about me from SMS. A photocopy or facsimile of this authorization shall be as valid as the original.*
I agree to the terms
In conjunction with my application for new or continuing employment (including contract and/or volunteer services) with you, I understand that you intend to hire Selection Management Systems, Inc. (“SMS”) to obtain Consumer Reports and/or Investigative Consumer Reports (“Reports”) about me as defined in the federal Fair Credit Reporting Act (“FCRA”). These Reports may include information concerning my academic background, character, credentials, credit capacity, credit standing, creditworthiness, general reputation, mode of living, personal characteristics, reasons for work termination, work experience, work habits and/or work performance. You may also seek information concerning my civil litigation history, criminal record, educational background, employment history, motor vehicle record, and/or worker’s compensation history.

I understand that you may rely on the information contained in these Reports in determining whether to extend an offer of employment to me or maintain my employment with you. I also understand that you may run Reports about me at least once every two years. If you contemplate making an adverse employment-related decision that will affect me based, in whole or in part, upon a Report obtained from SMS, I will receive a copy of the Report and a written summary of my Consumer Rights under the FCRA before you finalize that decision.

I have read the above disclosure and I hereby authorize you, SMS or its authorized agents to obtain the above-referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above-referenced knowledge or information they have concerning me. This authorization shall remain on file and be valid for the duration of my employment with you. It shall serve as an ongoing authorization for you to obtain Reports about me from SMS. A photocopy or facsimile of this authorization shall be as valid as the original.
*
Yes, I am checking this box to request to receive a free copy of any Consumer Report ordered about me. Send it to my email address provided above.
As the applicant, under California Civil Code Section 1786.22, you may view the file maintained on you by SMS during normal business hours. You may also obtain a copy of this file, either in person or by mail, by submitting proper identification and paying the costs of duplication services. You may also receive a summary of the file by telephone by being able to provide adequate identification to allow SMS to determine with reasonable certainty that you are the subject of the Report. SMS is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person, another person of your choice may accompany you, provided that this additional person also furnishes proper identification. The SMS Privacy Policy can be viewed at www.SelectionManagementSystems.com/Privacy-Policy/.*
Notice to California Residents
As the applicant, under California Civil Code Section 1786.22, you may view the file maintained on you by SMS during normal business hours. You may also obtain a copy of this file, either in person or by mail, by submitting proper identification and paying the costs of duplication services. You may also receive a summary of the file by telephone by being able to provide adequate identification to allow SMS to determine with reasonable certainty that you are the subject of the Report. SMS is required to have personnel available to explain your file to you and must explain to you any coded information appearing in your file. If you appear in person, another person of your choice may accompany you, provided that this additional person also furnishes proper identification. The SMS Privacy Policy can be viewed at www.SelectionManagementSystems.com/Privacy-Policy/.
THE FAIR CREDIT REPORTING ACT DISCLOSURE INFORMATION IS FOR PERMANENT RETENTION IN PERSONNEL FILE.

Employment Inquiry Release
In conjunction with my application for new or continuing employment (including contract and/or volunteer services) with you, I understand that you intend to hire Selection Management Systems, Inc. (“SMS”) to obtain Consumer Reports and/or Investigative Consumer Reports (Reports) about me as defined in the federal Fair Credit Reporting Act (“FCRA”). These Reports may include information concerning my academic background, character, credentials, credit capacity, credit standing, credit-worthiness, general reputation, mode of living, personal characteristics, reasons for work termination, work experience, work habits and/or work performance. You may also seek information concerning my civil litigation history, criminal record, educational background, employment history, motor vehicle record, and/or worker’s compensation history. I understand that you may rely on the information contained in these Reports in determining whether to extend an offer of employment to me or maintain my employment with you. I also understand that you may run Reports about me at least once every two years. If you contemplate making an adverse employment-related decision that will affect me based, in whole or in part, upon a Report obtained from SMS, I will receive a copy of the Report and a written summary of my Consumer Rights under the FCRA before you finalize that decision. I have read the above disclosure and I hereby authorize you, SMS or its authorized agents to obtain the above-referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above-referenced knowledge or information they have concerning me. This authorization shall remain on file and be valid for the duration of my employment with you. It shall serve as an ongoing authorization for you to obtain Reports about me from SMS. A photocopy or facsimile of this authorization shall be as valid as the original. I agree that any and all disputes arising from any Report shall be brought only in the state or federal court in Hamilton County, Ohio and shall be governed by, and construed in accordance with, the laws of the State of Ohio.*
In conjunction with my application for new or continuing employment (including contract and/or volunteer services) with you, I understand that you intend to hire Selection Management Systems, Inc. (“SMS”) to obtain Consumer Reports and/or Investigative Consumer Reports (Reports) about me as defined in the federal Fair Credit Reporting Act (“FCRA”). These Reports may include information concerning my academic background, character, credentials, credit capacity, credit standing, credit-worthiness, general reputation, mode of living, personal characteristics, reasons for work termination, work experience, work habits and/or work performance. You may also seek information concerning my civil litigation history, criminal record, educational background, employment history, motor vehicle record, and/or worker’s compensation history.

I understand that you may rely on the information contained in these Reports in determining whether to extend an offer of employment to me or maintain my employment with you. I also understand that you may run Reports about me at least once every two years. If you contemplate making an adverse employment-related decision that will affect me based, in whole or in part, upon a Report obtained from SMS, I will receive a copy of the Report and a written summary of my Consumer Rights under the FCRA before you finalize that decision.

I have read the above disclosure and I hereby authorize you, SMS or its authorized agents to obtain the above-referenced information about me. I also authorize all agencies, bureaus, employers, information service organizations and individuals to provide any of the above-referenced knowledge or information they have concerning me. This authorization shall remain on file and be valid for the duration of my employment with you. It shall serve as an ongoing authorization for you to obtain Reports about me from SMS. A photocopy or facsimile of this authorization shall be as valid as the original. I agree that any and all disputes arising from any Report shall be brought only in the state or federal court in Hamilton County, Ohio and shall be governed by, and construed in accordance with, the laws of the State of Ohio.
Yes, I accept the terms of the employment inquiry release.

Drug Testing Authorization & Consent
I, the undersigned, hereby knowingly and voluntarily authorize and consent to the collection and testing of specimens of my urine by a collection site and laboratory to be designated by Kalamazoo Long Term Care Pharmacy (KLTC Pharmacy) or its designated agent for the purpose of drug testing. I authorize the collection site, laboratory and medical review officer (MRO) to disclose the results of my drug tests to KLTC Pharmacy. I acknowledge that the drug test results will be utilized by KLTC Pharmacy to determine my eligibility for employment or continued employment. I acknowledge that at the time of collection, a refusal to authorize the collection and testing of my urine by the collection site and laboratory, or a refusal to authorize the above disclosure of the test results will be treated as a positive drug test. I further acknowledge that a positive drug test will result in disciplinary action up to and including denial of employment or termination, if hired. In addition, I hereby knowingly and voluntarily release KLTC Pharmacy, the collection site, the testing laboratory and their respective officers, directors, employees and agents from any and all claims, damages, losses, liabilities, costs and expenses, including attorney fees, arising from or relating to such collection and testing and any disclosure of the results thereof, including without limitation, the disclosure of any inaccurate or incomplete results, to the fullest extent permitted by law. I further authorize the testing laboratory to disclose the results of my drug screen to KLTC Pharmacy, or its agents, for a period not to exceed two years from the date of my signature below. I acknowledge that I have the right to receive a copy of this authorization. I have read and understood the above Authorization & Consent in its entirety, and I agree that a copy of this document is as valid as the original.*
I, the undersigned, hereby knowingly and voluntarily authorize and consent to the collection and testing of specimens of my urine by a collection site and laboratory to be designated by Kalamazoo Long Term Care Pharmacy (KLTC Pharmacy) or its designated agent for the purpose of drug testing.

I authorize the collection site, laboratory and medical review officer (MRO) to disclose the results of my drug tests to KLTC Pharmacy.

I acknowledge that the drug test results will be utilized by KLTC Pharmacy to determine my eligibility for employment or continued employment.

I acknowledge that at the time of collection, a refusal to authorize the collection and testing of my urine by the collection site and laboratory, or a refusal to authorize the above disclosure of the test results will be treated as a positive drug test. I further acknowledge that a positive drug test will result in disciplinary action up to and including denial of employment or termination, if hired.

In addition, I hereby knowingly and voluntarily release KLTC Pharmacy, the collection site, the testing laboratory and their respective officers, directors, employees and agents from any and all claims, damages, losses, liabilities, costs and expenses, including attorney fees, arising from or relating to such collection and testing and any disclosure of the results thereof, including without limitation, the disclosure of any inaccurate or incomplete results, to the fullest extent permitted by law.

I further authorize the testing laboratory to disclose the results of my drug screen to KLTC Pharmacy, or its agents, for a period not to exceed two years from the date of my signature below.

I acknowledge that I have the right to receive a copy of this authorization.

I have read and understood the above Authorization & Consent in its entirety, and I agree that a copy of this document is as valid as the original.
Yes, I accept the terms of Kalamazoo Long Term Care Pharmacy’s drug testing authorization & consent policy outlined here.

The facts set forth above in my application for employment are true and correct. I authorize the investigation of all information contained in this form to determine my suitability for employment at Kalamazoo Long Term Care Pharmacy. I understand that misrepresentation or omission of facts called for may be cause for dismissal. I also understand that regular employment depends on satisfactory replies from my references, drug screening and background investigation.

I understand that the employment relationship between Kalamazoo Long Term Care Pharmacy and its employees is at will, that employment is not for a definite period of time, and that either Kalamazoo Long Term Care Pharmacy or an employee may terminate the employment relationship at any time for any reason that is not contrary to law.
Your Name*
Please type your name here in lieu of a physical signature to indicate acceptance of the above terms. This application will be kept on file for a period of at least six (6) months.

Employment Application

Kalamazoo Long Term Care Pharmacy

Employment Application

Step 1 of 9

Personal Info

Present Address

Previous Address

Education

High School

High School Address

College

College Address

Graduate Study

Graduate School Address

Other Training

“Other Training” Address

References

Work Experience

Company Address

Fair Credit Reporting Act Disclosure

Employment Inquiry Release

Drug Testing Authorization & Consent