* Required Information

Employment Application

Instructions:

  • Please detach this instruction page prior to giving the application form to the applicant.
  • Please note that while Priority Professional Care has made this model employment application available in Word format, we generally advise against making changes and therefore are unable to make any changes on your behalf. This form should not be considered legal advice. Any changes made should be reviewed by your counsel.
  • This employment application can be used by applicants for any position within your company.

Criminal Record Information:

  • Some states require employers to wait until late in the selection process to ask about convictions. The policy rationale is that an employer is more likely to objectively assess the relevance of an applicant’s conviction if it becomes known when the employer is already knowledgeable about the applicant’s qualifications and experience. As a best practice, and consistent with applicable laws, the Equal Employment Opportunity Commission (“EEOC” - the federal government agency that enforces anti-discrimination laws) recommends that employers not ask about convictions on job applications and that, if and when they make such inquiries, the inquiries be limited to convictions for which exclusion would be job related for the position in question and consistent with business necessity. For this reason, there are no criminal record inquiries included with this application.
  • We strongly recommend that clients conduct appropriate criminal background checks on all applicants after a contingent offer of employment has been extended. In addition, clients must employ an individualized assessment when reviewing criminal history.
  • The EEOC guidance is available on the EEOC website below:
    http://www.eeoc.gov/laws/guidance/arrest_conviction.cfm
  • For assistance in evaluating criminal history based on the EEOC guidance and potentially applicable state law please contact your Human Resources Business Partner.

(PLEASE PRINT AND COMPLETELY ANSWER ALL QUESTIONS)

Our company (“Priority Professional Care”) fully subscribes to the principles of Equal Employment Opportunity. It is our policy to provide employment, compensation, and other benefits related to employment based on qualifications, without regard to race, color, religion, national origin, age, sex, veteran status, genetic information, disability, or any other basis prohibited by federal, state or local law. In accordance with requirements of the Americans with Disabilities Act and applicable federal, state and/or local laws, it is our policy to provide reasonable accommodation upon request during the application process to applicants in order that they may be given a full and fair opportunity to be considered for employment. As an Equal Opportunity Employer, we intend to comply fully with applicable federal, state and/or local employment laws and the information requested on this application will only be used for purposes consistent with those laws. To the extent required by applicable law, The Company maintains a smoke- free workplace.

Applicants for positions in Rhode Island please note that the company is subject to Chapters 29-38 of Title 28 of the General Laws of Rhode Island and is therefore covered by the state's workers compensation law unless this box is checked.

Personal Data

If you are under 18 years of age, please specify your age. (This information will be used only for child labor law purposes).

Note: It is not necessary for you to identify unavailability for work because of religious observance or practice or any other protected classification. Subsequent to any job offer, we will consider whether a reasonable accommodation can be made.

Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS Employment Eligibility Verification “Form I-9” be completed for every new hire and that within 3 business days of beginning work every new hire must present to the employer documentation establishing his/her identity and authorization to work. This federal requirement must be satisfied as a condition of employment.

Driving Record

(Answer only if driving is a requirement of the job for which you are applying).

Education

Describe any educational degrees, skills, training or experience you believe are relevant to the job applied for:

High School

College or University

Technical/GED

Licenses/Certification/Other

Employment History

Please complete for all full-time or part-time employment beginning with most recent employer. You may include as part of your employment history any verified work performed on a volunteer basis. All applicants should start with their most recent job, include military assignments and voluntary employment and provide ten (10) years of history. (A separate sheet may be attached.) You must explain any gaps in your employment history.

Dates Employed


Dates Employed


Dates Employed


Dates Employed


Professional References

(Please list three individuals unrelated to you with whom you have worked who know your qualifications for this position.)



Military

(Complete only if you served in the military.)

Lie Detector Tests

Massachusetts Applicants Note: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Maryland Applicants Note: An employer may not require or demand, as a condition or prospective employment or continued employment, 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. I have read and acknowledge this notice:

Applicant's Acknowledgment

I certify that the answers given herein and during the entire application process (including but not limited to information provided in resumes, attachments to this application, interviews or otherwise (if applicable)) are true and complete to the best of my knowledge.

I understand that any misrepresentations, omissions of facts or incomplete answers during the application process may disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts during the application process may be cause for my dismissal at any time without prior notice.

I consent to and authorize the Company to contact my former employers, references, and any and all other persons and organizations for information bearing upon my qualifications for employment.

I further authorize the listed employers, schools and personal references to give the Company (without further notice to me) any and all information about my previous employment and education, along with any other pertinent information they may have and hereby waive any actions which I may have against either party(ies) for providing a good faith reference.

I expressly agree and understand that, If employed, my employment is not for a specific term, is based on mutual consent and may be terminated by me or the company with or without notice or cause at any time. I further understand that no oral promise, employer policy custom, business practice or other procedure (including personnel handbook or any personnel manuals) consitute an employment contract or modification of the at-will employment relationship between me and the company. I also understand that my at-will employment status with the company may only be altered in an individual case or generally in a writing signed by the owner, President or CEO of the company.

I understand I may be required to qualify for employment based on additional employment criteria. For example, I may be required to take job-related tests; take a driver’s examination or take a pre-employment drug test. If I am offered employment or start work before any required test is completed, I understand that my employment is contingent on a satisfactory result on all required tests. I authorize the release of any drug/alcohol test to any state or federal authority requesting such information and in response to a valid subpoena or other legal document. I agree to sign any additional forms necessary for drug tests to be conducted.

CALIFORNIA APPLICANTS ONLY:

I understand the Company may obtain, without using the services of a third party investigative consumer reporting agency, public records pertaining to my character, general reputation, personal characteristics or mode of living during its evaluation of my application for employment and, if employed, during my employment. By checking the following box, I waive my right to receive copies of public records obtained by the Company.

Attachments

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