Employment Application – Crown Pointe

Applicant Notice:

You must read and agree to the following ‘conditions of employment;’ then sign below.

THIS IS A DRUG-FREE WORKPLACE

ANY PERSON EMPLOYED BY THIS FACILITY SHALL BE SUBJECT TO RANDOM DRUG OR ALCOHOL TESTING AT ANY TIME AND AT
THE FACILITY’S DISCRETION.

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POST- EMPLOYMENT PHYSICAL

THIS FACILITY REQUIRES ALL EMPLOYEES TO HAVE A MEDICAL EXAMINATION. AFTER AN EMPLOYMENT OFFER HAS BEEN MADE
TO A JOB APPLICANT AND BEFORE THE APPLICANT BEGINS THEIR EMPLOYMENT DUTIES, THEY MUST HAVE A MEDICAL
EXAMINATION.

ALL OFFERS OF EMPLOYMENT ARE MADE CONTINGENT ON THE MEDICAL EXAMINATION RESULTS. THE SUCCESSFUL APPLICANT
MUST BE QUALIFIED AND MUST BE ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITION THEY HAVE APPLIED FOR,
WITH OR WITHOUT REASONABLE ACCOMMODATIONS.

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CRIMINAL RECORD’S CHECK

TO BE ELIGIBLE FOR EMPLOYMENT WITH THIS FACILITY, EVERY EMPLOYEE WILL BE CHECKED AGAINST THE OIG EXCLUSION
CHECKLIST (PRE-EMPLOYMENT and PERIODICALLY POST-EMPLOYMENT). EVERY EMPLOYEE MUST SUBMIT TO A CRIMINAL
RECORDS CHECK WITHIN 5 DAYS OF EMPLOYMENT.

WHEN EMPLOYED, THE APPLICANT WILL BE CHARGED $22.00 FOR THE COST OF THE BCI&I (Ohio Bureau of Criminal
Identification and Investigation) CRIMINAL RECORDS’ CHECK. IF THE EMPLOYEE-APPLICANT HAS NOT BEEN A RESIDENT
OF OHIO FOR MORE THAN 5 YEARS, THEY WILL ALSO BE CHARGED $29.00 FOR THE COST OF THE FBI (Federal Bureau of
Investigation) CRIMINAL RECORDS CHECK.

THE COST OF THE RECORDS CHECK SHALL BE DEDUCTED FROM THE EMPLOYEE’S FIRST PAYCHECK, THROUGH A PAYROLL
DEDUCTION. BECAUSE THIS IS A ‘CONDITION OF EMPLOYMENT,’ AN APPLICANT WILL NOT BE CONSIDERED FOR EMPLOYMENT
WITHOUT THEIR AGREEMENT TO PAY FOR THE REQUIRED CRIMINAL RECORDS’ CHECK. (Your signature is required below.)

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I have read and understand the above listed requirements. I understand my employment with the Facility is
“at will” and is contingent upon the successful passage of my criminal background check, past employment
references and my post-employment medical examination.

With my signature, I certify that I currently not under investigation for or been convicted of a crime that
may exclude me from employment in a nursing facility. I also understand that a criminal records check is a
condition of employment and that I will be responsible for the cost of said records’ check. I HEREBY APPROVE
the deduction of the associated cost of said records check(s) from my paycheck.

Print Applicant’s Name

Date

Personal Information

First Name

Last Name

Middle Name

Have you ever been known by a different name(s)?If Yes, what names?

Address:

City/ State:

Zip Code:

Home/ Cell Phone:

Social Security No.:

Alternate Contact#:

Email:

Position Applying For:

Date Available:

Full TimePart TimePRN
Preferred Hours

First ShiftSecond ShiftThird Shift (if available)
Preferred Shifts

YesNo
Overtime

YesNo
Weekends

YesNo
Holidays

n/aYesNo
Irregular Schedule

Expected Hourly Rate of Pay:

How did you find out about position?

Please clarify.

YesNo
Have you applied/ worked with us before?

If yes, when and for what position?

YesNo
Have you applied/ worked for any other FOUNDATIONS HEALTH SOLUTIONS managed or related facility?

If yes, when and for what location and position?

Education

YesNo
Completed High School:

n/aYesNo
GED:

Name and Location of High School:

Certification or Other Training/ Skills:

n/aYesNo
Graduate School:

Name and Location of College:

Degree / Area of Study:

License # (if applicable & required for the position in which you are applying)

If a license/professional certification is required for the position in which you are applying (Examples:
LPN, RN, STNA, LSW), are you currently under investigation or have any active/pending suspensions/violations
on your license to practice?

n/aYesNo
Choose Your Answer

Legal

YesNo
Are you 18 years of age or over?

n/aYesNo
If No, do you have a work permit?

YesNo
Are you eligible to work in the United States?

n/aYesNo
If no, do you have the necessary documents to establish your eligibility?

Alien Registration No.

Alien Registration Expiration Date

YesNo
WILL YOUR BACKGROUND CHECK REVEAL ANY CONVICTIONS OR GUILTY PLEAS?

This includes any conviction(s) that occurred when you were a minor or records that have been sealed or
expunged.

ARE YOU CURRENTLY UNDER INVESTIGATION OR HAVE EVER BEEN CONVICTED OF RESIDENT ABUSE, A MEDICARE OR MEDICAID
OFFENSE OR BEEN EXCLUDED FROM PARTICIPATION IN A STATE OR FEDERAL HEALTH CARE PROGRAM THAT WOULD PRECLUDE
YOU FROM WORKING IN A NURSING FACILITY?

YesNo
Choose Your Answer

In accordance with 42 U.S. Code § 1320a-7 and ORC § 3721.121, you are notified that this Company is required
to complete an OIG Exclusion Check at the time of application and periodically after employment; and will
search your criminal background. Any “convictions of”, “pleading guilty to”, or “no contest pleas” to the
attached listed offenses, when required, will result in termination. If the criminal background check is not
returned to us within 30 days of your date of hire, you will be suspended and subject to be terminated.

References:

Name/ Address of 3 persons, not related, whom you have known at least one year, include phone number.

Reference 1 Name

Phone

Email

Reference 2 Name

Phone

Email

Reference 3 Name

Phone

Email

Employment History

List employment with your most recent or current position first. Account for any time during this period
that you were unemployed by stating the nature of your activities. Please indicate if you were employed
under a different name. We are required to complete employment reference checks.

n/aYesNo
May we contact your present employer?

Company Name

Phone

Address

City/ State/ Zip

Job Title

Supervisor

Dates of Employment-Start:

Ending Date:

Duties Included:

Reason for Leaving:

Company Name 2

Phone

Address

City/ State/ Zip

Job Title

Supervisor

Dates of Employment-Start:

Ending Date:

Duties Included:

Reason for Leaving:

Company Name 3

Phone

Address

City/ State/ Zip

Job Title

Supervisor

Dates of Employment-Start:

Ending Date:

Duties Included:

Reason for Leaving:

Company Name 4

Phone

Address

City/ State/ Zip

Job Title

Supervisor

Dates of Employment-Start:

Ending Date:

Duties Included:

Reason for Leaving:

YesNo
2903.01 AGGRAVATED MURDER; SPECIFIC INTENT TO CAUSE DEATH

YesNo
2903.02 MURDER

YesNo
2903.03 VOLUNTARY MANSLAUGHTER

YesNo
22903.04 INVOLUNTARY MANSLAUGHTER

YesNo
2903.11 FELONIOUS ASSAULT

YesNo
2903.12 AGGRAVATED ASSAULT

YesNo
2903.13 ASSAULT

YesNo
2903.16 FAILING TO PROVIDE FOR A FUNCTIONALLY IMPAIRED PERSON

YesNo
2903.21 AGGRAVATED MENACING

YesNo
2903.34 PATIENT ABUSE OR NEGLECT

YesNo
2905.01 KIDNAPPING

YesNo
2905.02 ABDUCTION

YesNo
905.11 EXTORTION

YesNo
2905.12 COERCION

YesNo
2907.02 RAPE

YesNo
2907.03 SEXUAL BATTERY

YesNo
2907.05 GROSS SEXUAL IMPOSITION

YesNo
2907.06 SEXUAL IMPOSITION

YesNo
2907.07 IMPORTUNING

YesNo
2907.08 VOYEURISM

YesNo
2907.09 PUBLIC INDECENCY

YesNo
2907.12 FELONIOUS SEXUAL PENETRATION

YesNo
2907.25 PROSTITUTION

YesNo
2907.31 DISSEMINATING MATTER HARMFUL TO JUVENILES

YesNo
2907.32 PANDERING OBSCENITY

YesNo
2907.321 PANDERING OBSCENITY INVOLVING A MINOR

YesNo
2907.322 PANDERING SEXUALLY ORIENTED MATTER INVOLVING A MINOR

YesNo
2907.323 ILLEGAL USE OF A MINOR IN NUDITY-ORIENTED MATERIAL OR PERFORMANCE

YesNo
2911.01 AGGRAVATED ROBBERY

YesNo
2911.02 ROBBERY

YesNo
2911.11 AGGRAVATED BURGLARY

YesNo
2911.12 BURGLARY

YesNo
2911.13 BREAKING AND ENTERING

YesNo
2913.02 THEFT, AGGRAVATED THEFT

YesNo
2913.03 UNAUTHORIZED USE OF A VEHICLE

YesNo
2913.04 UNAUTHORIZED USE OF PROPERTY; UNAUTHORIZED ACCESS TO COMPUTER SYSTEMS

YesNo
2913.11 PASSING BAD CHECKS

YesNo
2913.21 MISUSE OF CREDIT CARDS

YesNo
2913.31 FORGERY

YesNo
2913.40 MEDICAID FRAUD

YesNo
2913.43 SECURING WRITINGS BY DECEPTION

YesNo
2913.47 INSURANCE FRAUD

YesNo
2913.51 RECEIVING STOLEN PROPERTY

YesNo
2919.25 DOMESTIC VIOLENCE

YesNo
2921.36 PROHIBITION OF CONVEYANCE OF CERTAIN ITEMS ONTO GROUNDS OF DETENTION FACILITY OR MENTAL HEALTH
OR MENTAL RETARDATION AND DEVELOPMENTAL DISABILITIES FACILITY

YesNo
2923.12 CARRYING CONCEALED WEAPONS

YesNo
2923.13 HAVING WEAPONS WHILE UNDER DISABILITY

YesNo
2923.161 IMPROPERLY DISCHARGING FIREARM AT OR INTO HABITATION OR SCHOOL

YesNo
2925.02 CORRUPTING ANOTHER WITH DRUGS

YesNo
2925.03 TRAFFICKING OFFENSES

YesNo
2925.11 DRUG ABUSE; CERTAIN VIOLATIONS DO NOT CONSTITUTE CRIMINAL RECORD

YesNo
2925.13 PERMITTING DRUG ABUSE

YesNo
2925.22 DECEPTION TO OBTAIN A DANGEROUS DRUG

YesNo
2925.23 ILLEGAL PROCESSING DRUG DOCUMENT

YesNo
3716.11 ADULTERATION OF FOOD

YesNo
Are you currently or have you ever been investigated, sanctioned, fined or criminally charged or
convicted by a State or Federal Agency or Governing Board?

YesNo
Are you currently or have you ever been convicted of Resident Abuse or any Medicaid or Medicare offense
or excluded from participation in the Federal Health Care Programs?

Please Read Carefully. By signing below, I attest the information provided is truthful and
complete.

In submitting this application for employment, I understand that an investigation may be made whereby
information is obtained regarding my character, previous employment, and/ or criminal history. I authorize
anyone possessing this information to furnish it to the Company listed on the front of this application and
I release anyone so authorized from all liability and damages whatsoever in furnishing, obtaining or using
said information. In the event of employment, I understand that false or misleading information given in my
application or during my interview may result in immediate dismissal. I understand, also, that I am required
to abide by all rules and regulations of this Company. I understand my employment is contingent upon the
completion of an OIG Exclusion Check, a Nurse Aide Registry Check and a successful criminal background check
on or before hire. I understand and agree that if employed, my employment will be “at-will”. That is, either
I or the Company may end the employment relationship at any time, for any reason. I understand that receipt
of this application does not imply employment and that this application and/ or any other Company documents
are not contracts of employment.

Applicant’s Acknowledgment/ Approval

Date

Print Applicant’s Name