Employment Opportunities

Name

Current Address

Prior Address

Have you ever lived outside of the state of Pennsylvania in the last two years? YesNo

Are you under 18 years of age? YesNo

It is agency policy that members of the same family may not work within the same chain of command or where there is a potential for conflict of interest. To avoid work assignments that may violate this policy (if hired), please provide the following information about any of your family member currently working for our agency.

Do you have an automobile that can be used in conjunction with your, work? YesNo

Are you legally eligible to work for any employer in the United States? YesNo

Have you previously applied for employment, with Fatima Health Services Inc.? YesNo. If "Yes", date:

Have you ever worked for Fatima Health Services Inc.?YesNo. If "Yes", date:

Position(s) applied for

Will you work

What experiences, skills, and /or qualification(s) do you have that qualify you for the position(s) you applied for?

Have you ever been convicted of a crime? A conviction may not automatically bar you from employment. The nature of the Crime, type of crime, and date of conviction. will be considered in determining your eligibility for employment. YesNo

If "Yes"

As a professional, have you ever been disciplined by a professional group, organization, licensure board, etc.? Discipline by a professional group will not automatically bar you from employment unless otherwise provided by law. The nature and date of the discipline will be considered in determining your eligibility for employment. YesNo

If "Yes"

Have you ever been excluded from participation in a federal health care program such as Medicare or Medicaid by way of payment or employment? YesNo

If "Yes"

List below all present and past employment, beginning with your most recent. If needed, use an additional sheet to list all previous employment.
1.

Were you disciplined, suspended or terminated for: Patient Care? YesNo

Other violations of your previous employer’s policy? YesNo

2.

Were you disciplined, suspended or terminated for: Patient Care? YesNo

Other violations of your previous employer’s policy? YesNo

3.

Were you disciplined, suspended or terminated for: Patient Care? YesNo

Other violations of your previous employer’s policy? YesNo

4.

Were you disciplined, suspended or terminated for: Patient Care? YesNo

Other violations of your previous employer’s policy? YesNo

May we contact your previous employers? YesNo

If no, indicate which previous employer(s) you do not want us to contact and why:

Record of Education

Professional/Personal References

List three (at least two not related to you).

Important: Read Carefully

I hereby certify that the inforn1ation provided in this application (and accompanying resume, if any) is true and complete. I understand that any false, incomplete or misleading information given by me on this form, regardless of when it is discovered1 may disqualify me from further consideration for employment and may be justification for termination of my employn1ent, if discovered at a later d ate.

I hereby authorize Fatima Health Services Inc., or its affiliates to investigate all statements contained in this application and in so doing to contact and obtain information from all references, employers, educational institutions, law enforcement agencies and any other organizations referenced in this application. I also release Fatima Health Services Inc. from any liability arising there front and release former employers and references from any liability in furnishing information pertaining to my background and work experience.

I agree to immediately notify Fatima Health Services Inc. if I should be arrested or convicted of any criminal offense while my job application is pending, or during my period of employment if hired.

I hereby agree that I have no specific rights of privacy in any property brought onto the work premises of Fatima Health Services Inc., and consent to the search of any and all personal property and items brought onto Fatima Health Services Inc. work premises. Fatima Health Services Inc. work premises includes any location (including patient residence) that I may be assigned to work by Fatima Health Services Inc.

I recognize that any offer of employment is conditioned on the satisfactory completion of all relevant aspects of my background check and a health screening, and I hereby consent to said background check and health screening.

I understand that, if employed, Fatima Health Services Inc. or I may terminate the employment relationship at any time, with or without cause, with or without notice; and that, if employed, employment does not constitute a contract of employment between Fatima Health Services Inc. and myself.

I understand that no representative of Fatima Health Services Inc., other than its Executive Director, has any authority to enter in to any agl'een1ent for employment for any specified period of time, or to make any agreement contrary to the foregoing, and that any such agreement must be in writing.

This application will be considered current for sixty (60) days from this date. After that time, the application must be renewed to be considered.

Fatima Health Services Inc. is an Equal Opportunity Employer, dedicated to a policy of nondiscrimination in all employment on any basis including age, sex, color, race, creed, national origin, religious persuasion, marital status or disability.