Disclaimer and Electronic Signature
- That completing this application does not constitute an offer of employment and that my application may be rejected for any reason.
- That giving false or misleading information on this form or in an interview is grounds for denial or immediate termination of employment.
- That I may be required to complete a medical history form and may be required to be examined by a medical professional designated by Regency Post-Acute, Rehab & Nursing Center.
- That if I sustain any injury or illness in the employment of Regency Post-Acute, Rehab & Nursing Center, I agree that Regency Post-Acute, Rehab & Nursing Center shall be entitled to receive full and complete reports and records covering any medical or related exams, and I authorize any and all such doctors, medical examiners, and hospitals to give to Regency Post-Acute, Rehab & Nursing Center full and complete reports and records covering such examinations, condition, care, and treatment related to or resulting from the alleged illness or injury.
- THAT IF HIRED MY EMPLOYMENT WILL BE "AT WILL" WHICH MEANS THAT I OR THE EMPLOYER CAN TERMINATE MY EMPLOYMENT FOR ANY OR NO REASON WITH OR WITHOUT NOTICE
Authorization to Release Information:
If I am given a conditional offer of employment, I authorize Regency Post-Acute, Rehab & Nursing Center to make a complete investigation of me, including but not limited to: my past employment history, medical history, scholastic records, criminal records, abuse records, motor vehicle driving records, workers’ compensation history and to rely on such information sources. I authorize all persons and organizations to release any information concerning my background and hereby release all persons and organizations from liability for any damage whatsoever for issuing this information. I acknowledge that a telephone facsimile (fax) or photographic copy shall be as valid as the original.
By checking below, I certify that I have not been convicted of an offense that would preclude working in a nursing facility. I also certify that I am not excluded from participation in federal health care programs. Furthermore, I understand that I will be subject to a search of the OIG List of Excluded Individuals, and that a comprehensive criminal background screening will be completed by a third party organization acting on behalf of Regency Post-Acute, Rehab & Nursing Center. If the findings of that background screening result in a refusal to hire, I will be notified in writing and may request a copy of the findings from the third party organization.
I understand that the use of illegal drugs is prohibited during employment. If employment policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and/or during employment.
I understand that this employment application and any other employee-related documents are not contracts of employment; and that any individual who is hired may voluntarily leave employment upon proper notice, and may be terminated by the employer at any time for any reason. I understand that any oral or written statements to the contrary are hereby expressly disavowed and should not be relied upon by any prospective or existing employee.
I certify that my answers are true and complete to the best of my knowledge.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.