Online Application
IMPORTANT: Please read these instructions before you begin your application, failure to do so may result in having to complete another application:
Complete all areas of the application (even if attaching /uploading a resume). Review of your application, by the recruiter, will include a full review of your work history including dates of employment, etc. and it is most important that you provide all pertinent information into those fields.
Use both upper and lower case letters, do not use ALL CAPS.
Fields marked with
CAREFULLY READ THIS SECTION PRIOR TO PROVIDING SIGNATURE BELOW
I consent to any medical examination required by A Caring Hand LLC at any time to determine my ability to perform the duties of my job with ACH. I understand that I will be required to satisfactorily complete an alcohol/drug screening as a condition of employment. I further understand that a positive and properly confirmed drug test for controlled substances or refusal to submit to a drug test is grounds for denial or termination of employment.
I understand that my employment can be terminated at any time and for any reason, at the option of either the employer or myself. 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 an authorized representative of ACH.
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) and previous employers and organizations named in this application (and accompanying resume, if any) to provide ACH 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. I understand that ACH may use the services of an outside agency to conduct reference checks. I hereby authorize any such agency to provide relevant information to ACH and I release all such agencies, their directors, officers, agents and employees from any liability regarding the provision of such information.
My typed name below shall have the same force and effect as my written signature.
Signature
Date
PERSONAL INFORMATION
First Name
Middle Name
Last Name
Last 4 Digits of SSN
Email Address
Daytime Phone
Evening Phone
WORK STATUS INFORMATION
Other names you have worked under
Are you a U.S. citizen or authroized to work in the U.S. on an unrestricted basis?
Can you, at the time of orientation, submit proof of your legal right to work in the U.S.?
Can you, at the time of orientation, submit a birth certificate or other proof of age?
POSITION INFORMATION
Salary Requirement
Were you previously employed by VNHSC, A Caring Hand, ECHN or their affiliates?
If yes, when/where?
Names of relatives employed by VNSHC, A Caring Hand, ECHN or their affiliates?
If an offer is extended, when would you be available for work?
How did you become aware of the position for which you are applying?
Do you have your own reliable vehicle?
EDUCATION LEVEL
LICENSE INFORMATION
Driver's license
Driver's license
Driver's license expiration date
License No.
State Issued
Expiration Date
EMPLOYMENT INFORMATION
This section must be completed in full
Are you presently employed?
May we contact your present employer?
Starting with your most recent position, state your last three employment experiences, please complete even if application is accompanied by a resume.
Most Recent Employment
Start Date MM/YYYY
End Date MM/YYYY
Name of Employer
City
State
Zip
Supervisor
Phone
Job Title & Duties
Starting Salary
Ending Salary
Reason for Leaving
Second Most Recent
Start Date MM/YYYY
End Date MM/YYYY
Name of Employer
City
State
Zip
Supervisor
Phone
Job Title & Duties
Starting Salary
Ending Salary
Reason for Leaving
Third Most Recent
Start Date MM/YYYY
End Date MM/YYYY
Name of Employer
City
State
Zip
Supervisor
Phone
Job Title & Duties
Starting Salary
Ending Salary
Reason for Leaving
ADDITIONAL INFORMATION
Do you speak, read or write in any language other than English?
Please use this space to list and/or describe any additional skills you possess (i.e. computer hardware/software, typing (wpm), etc.
Can you perform the essential functions of the job you are applying for with or without reasonable accommodations.
If no is checked, please list below special accommodations that would be necessary:
BACKGROUND CONSENT
FCRA DISCLOSURE AND ACKNOWLEDGMENT
IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION
DISCLOSURE REGARDING BACKGROUND INVESTIGATION
Eastern Connecticut Health Network (�the Company�) may obtain information about you from a
consumer reporting agency for employment purposes from a third party consumer reporting
agency. Thus, you may be the subject of a �consumer report� and/or an �investigative consumer
report� which may contain information regarding your criminal history, social security
verification, motor vehicle records (�driving records�), verification of your education or
employment history, or other background checks. An investigative consumer report may also
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. Please be advised that the nature and scope of the most common form of
investigative consumer report obtained is an investigation into your education and/or
employment history. You have the right, upon written request made within a reasonable time, to
request disclosure of the nature and scope of any investigative consumer report.
The report will be generated by Universal Background Screening (7720 North 16th Street, Suite
200, Phoenix, AZ 85020, 1-877-263-8033, www.universalbackground.com) or another outside
organization. The scope of this notice and authorization is all-encompassing, however, allowing
the Company to obtain from any outside organization all manner of consumer reports and
investigative consumer reports now and, if you are hired, throughout your employment to the
extent permitted by law now and throughout the course of your affiliation with the Company, 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 the Company by contacting the
consumer reporting agency identified above directly. You may also contact the Company to
request the name, address and telephone number of the nearest unit of the consumer reporting
agency designated to handle inquiries, which the Company shall provide within 5 days.
New York applicants or employees only: Upon request, you will be informed whether or not a
consumer report was requested by the Company, and if such report was requested, informed of
the name and address of the consumer reporting agency that furnished the report. By signing
below, you also acknowledge receipt of Article 23-A of the New York Correction Law.
Oregon applicants or employees only: Information describing your rights under federal and
Oregon law regarding consumer identity theft protection, the storage and disposal of your credit
information, and remedies available should you suspect or find that the Company has not
maintained secured records is available to you upon request.
Washington State applicants or employees only: You also have the right to request from the
consumer reporting agency a written summary of your rights and remedies under the Washington
Fair Credit Reporting Act.
ACKNOWLEDGMENT AND AUTHORIZATION
I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND
INVESTIGATION (above) and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR
CREDIT REPORTING ACT (separate document) 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� by the Company at any time after receipt of this authorization
and, if I am hired, throughout my employment and throughout my affiliation with the Company,
if applicable. 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 Universal Background Screening, another outside organization acting
on behalf of the Company, and/or the Company 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 signing below, you also acknowledge receipt of
Article 23-A of the New York Correction Law.
Minnesota and 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 signing below, By signing below, By signing
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 at no charge
if one is obtained by the Company whenever you have a right to receive such a copy under
California law.
This information will be used for background screening purposes only and will not be used as hiring criteria.
