Kernodle Clinic. Application for Employment

Transcription

1 Kerndle Clinic Applicatin fr Emplyment Easttwn Graham-Hpedale Rad Eln Williamsn Avenue Mebane Medical Park Drive West Huffman Mill Rad Return cmpleted frm t: Kerndle Clinic Human Resurces 1234 Huffman Mill Rad, Burlingtn, NC Phne: (336) Facsimile: (336) Kerndle Clinic s missin is t prvide superir medical care in a persnalized manner.

2 Kerndle Clinic Applicatin fr Emplyment We cnduct pre-emplyment drug screens. Persnal Infrmatin Name Applicatin Date Street Address City/State/Zip Hme Phne Best Time t Call Wrk Phne Best Time t Call Other Phne Best Time t Call May we cntact yu at wrk? Yes N Type f Emplyment Sught: Full-Time Part-Time Temprary Type f Applicatin: New Emplyee Rehire Are yu willing t wrk vertime if required? Yes N Date Available fr Emplyment Minimum Salary Acceptable Psitin(s) Fr Which Yu are Applying: General Infrmatin 1. Are yu eligible t accept permanent emplyment in this cuntry? Yes N 2. Have yu been cnvicted f a crime (misdemeanr r felny), ther than minr traffic ffenses? Yes N If yes, please describe the nature, date, lcatin and final dispsitin f the case. (A cnvictin des nt autmatically disqualify yu frm emplyment. The ffense and hw recently yu were cnvicted will be evaluated in relatin t the jb fr which yu are applying.) 3. Have yu interviewed fr a psitin at Kerndle Clinic in the past 12 mnths? Yes N 4. Have yu ever been emplyed by Kerndle Clinic? Yes N If yes, please indicate emplyment date(s), department(s), psitin(s) held and name, if different than current name.

3 Kerndle Clinic Applicatin fr Emplyment We cnduct pre-emplyment drug screens. Educatin and Training High Schl Name Lcatin Did Yu Graduate? Yes N Cllege(s)/University(ies) Name Lcatin Majr/Minr Degree Received Graduate r Prfessinal Schl Name f Institutin Lcatin Cursewrk Degree/Certificatin Received Other Educatin, Vcatinal Schls, Internships, etc. Prfessinal Licenses/Certificatins Type State Expiratin Date Registratin Number What factr mst influenced yu t apply at Kerndle Clinic? Clinic reputatin Previusly emplyed by Kerndle Clinic Recmmendatin by Kerndle Clinc emplyee: Name f emplyee Relcated t the Area Walk-in Newspaper ad: Name f newspaper Other

4 Emplyment Histry Beginning with yur mst recent psitin, list all emplyment during the past ten years. If additinal space is needed, please use a cntinuatin sheet. Yu may submit a resume as a supplement but nt as a substitute fr this sectin. Emplyer City/State Jb Title Full-time Part-time Temprary Hire Date Separatin Date Rate f Pay Duties Reasn fr Leaving Supervisr s Name Phne Number May we cntact them fr a reference? Yes N Later Emplyer City/State Jb Title Full-time Part-time Temprary Hire Date Separatin Date Rate f Pay Duties Reasn fr Leaving Supervisr s Name Phne Number May we cntact them fr a reference? Yes N Later Emplyer City/State Jb Title Full-time Part-time Temprary Hire Date Separatin Date Rate f Pay Duties Reasn fr Leaving Supervisr s Name Phne Number May we cntact them fr a reference? Yes N Later I certify that all statements n this applicatin are true and cmplete t the best f my knwledge. I understand that any falsificatin r material missin in this applicatin may result in the rejectin f my applicatin r my dismissal if I am emplyed. I understand that any emplyment at Kerndle Clinic is n an at will basis. If emplyed by the Clinic, my emplyment and cmpensatin can be terminated with r withut ntice at any time by me r the Clinic fr any reasn. Further, I understand that nthing in this applicatin r any Clinic plicies r prcedures are intended t create a cntract fr emplyment fr any perid f time. I authrize my current emplyer and all previus emplyers, educatinal institutins, and/r registratin and licensing bards t prvide Kerndle Clinic with any wrk-related infrmatin requested. In ding s, I waive any bjectins t these surces issuing such infrmatin and I hereby release these surces frm any claims and liability fr prviding infrmatin requested. I understand any ffer f emplyment is cntingent upn successfully cmpleting the drug screening test. Signature Date

5 Ntificatin and Release Kerndle Clinic Cnsent t Request Cnsumer Reprt & Investigative Cnsumer Reprt Infrmatin Applicant s First Name r Initial Last Name I understand that Kerndle Clinic ( COMPANY ) will utilize the services f Sterling InfSystems Inc., 249 West 17th Street, New Yrk, NY 10011, (800) t btain a cnsumer reprt and/r investigative cnsumer reprt as part f the prcedure fr prcessing my applicatin fr emplyment. I als understand that if my applicatin fr emplyment is granted, t the extent permitted by law, COMPANY may btain further infrmatin thrugh subsequent investigatins by STERLING s as t update, renew r extend my emplyment. I understand Sterling InfSystems Inc. ( STERLING ) investigatin may include btaining infrmatin regarding my credit backgrund, bankruptcies, driving recrd, lawsuits, judgments, paid tax liens, unlawful detainer actins, failure t pay spusal r child supprt, accunts placed fr cllectin, and criminal recrd, subject t any limitatins impsed by applicable federal and state law. I understand such infrmatin may be btained thrugh direct r indirect cntact with frmer emplyers, schls, financial institutins, landlrds and public agencies r ther persns wh may have such knwledge. If an investigative cnsumer reprt is being requested, I understand such infrmatin may be btained thrugh any means, including but nt limited t persnal interviews with my acquaintances and/r assciates r with thers whm I am acquainted r wh may have knwledge cncerning my character, general reputatin, persnal characteristics r standard f living. I understand that I have the right t receive ntice abut the nature and scpe f any investigative cnsumer reprt requested within five days after the COMPANY receives my request r five days after the investigative cnsumer reprt was requested, whichever is later. By checking the bx, I indicate that I wish t receive further disclsure abut the nature and scpe f any COMPANY request fr an investigative cnsumer reprt. I acknwledge that I have received the attached summary f my rights under the Fair Credit Reprting Act and, as required by law, any related state summary f rights. This cnsent will nt affect my ability t questin r dispute the accuracy f any infrmatin cntained in my reprt. I understand if COMPANY makes a cnditinal decisin t disqualify me based all r in part n my reprt, I will be prvided with a cpy f the reprt and anther descriptin in writing f my rights under the federal Fair Credit Reprting Act and, as required by law, any related state summary f rights, and if I disagree with the accuracy f the purprted disqualifying infrmatin in the reprt, I must ntify COMPANY within five business days f my receipt f the reprt that I am challenging the accuracy f such infrmatin with Sterling InfSystems Inc. I hereby cnsent t this investigatin and authrize COMPANY t prcure a cnsumer reprt(s) and/r investigative cnsumer reprt n my backgrund as stated abve frm a cnsumer reprting agency and/r investigative cnsumer reprting agency. In rder t verify my identity fr the purpses f backgrund identificatin, I am vluntarily releasing my date f birth, scial security number and the ther infrmatin belw fr my wn benefit and fully understand that all emplyment decisins are based n legitimate nn-discriminatry reasns. Minnesta & Oklahma Applicants Only: I have the right t request a cpy f the cnsumer reprt btained by COMPANY frm STERLING by checking the bx. STERLING will mail the cnsumer reprt directly t me. I wish t receive a cpy f the cnsumer/investigative cnsumer reprt. (Check nly if yu wish t receive a cpy.) Maine Applicants Only: By checking the bx, I indicate that I wish t receive the name, address and telephne number f the nearest unit f the cnsumer reprting agency designated t handle inquiries regarding the investigative cnsumer reprt. Washingtn State Applicants Only (AS APPLICABLE): I further understand that COMPANY will nt btain infrmatin abut my credit wrthiness, credit standing, r credit capacity unless the infrmatin is required by law, r is substantially jb related, and the reasns fr using the infrmatin are disclsed t me in writing. (If this ptin is checked, cmplete the questin belw.) Reasns why COMPANY cnsiders infrmatin abut credit wrthiness, credit standing, r credit capacity as substantially jb related: NY Applicants Only: I als acknwledge that I have received the attached cpy f Article 23A f New Yrk s Crrectin Law. I further understand that I may review and receive a cpy f any investigative cnsumer reprt by cntacting the cnsumer reprting agency. I further understand that I will be advised if any further checks are requested and prvided the name and address f the cnsumer reprting agency. Signature: Tday s Date:

6 Ntificatin and Release Kerndle Clinic K E R N O D L E Fr Office Use Only - Grup ID (Optinal) Fr Office Use Only - User ID (Optinal) Fr Office Use Only - Lcatin / Stre # (Optinal) First Name Middle Name r Initial Last Name Date f Birth (MMDDYYYY) Other Names Knwn By Male Female Scial Security Number Primary Telephne Number (n dashes) Current Address Apt # # yrs at this address City State Zip Cde Previus Address Apt # # yrs at this address City State Zip Cde Driver s License Number (n dashes) License State Address Signature Tday s Date (MMDDYYYY)

7 Ntificatin and Release Kerndle Clinic Para infrmacin en espanl, visite escribe a la FTC Cnsumer Respnse Center, Rm 130-A 600 Pennsylvania Ave. N.W., Washingtn, D.C A Summary f Yur Rights Under the Fair Credit Reprting Act The federal Fair Credit Reprting Act (FCRA) prmtes the accuracy, fairness, and privacy f infrmatin in the files f cnsumer reprting agencies. There are many types f cnsumer reprting agencies, including credit bureaus and specialty agencies (such as agencies that sell infrmatin abut check writing histries, medical recrds, and rental histry recrds). Here is a summary f yur majr rights under the FCRA. Fr mre infrmatin, including infrmatin abut additinal rights, g t r write t: Cnsumer Respnse Center, Rm 130-A, Federal Trade Cmmissin, 600 Pennsylvania Ave. N.W., Washingtn, D.C Yu must be tld if infrmatin in yur file has been used against yu. Anyne wh uses a credit reprt r anther type f cnsumer reprt t deny yur applicatin fr credit, insurance, r emplyment r t take anther adverse actin against yu must tell yu, and must give yu the name, address, and phne number f the agency that prvided the infrmatin. Yu have the right t knw what is in yur file. Yu may request and btain all the infrmatin abut yu in the files f a cnsumer reprting agency (yur file disclsure ). Yu will be required t prvide prper identificatin, which may include yur Scial Security number. In many cases, the disclsure will be free. Yu are entitled t a free file disclsure if: a persn has taken adverse actin against yu because f infrmatin in yur credit reprt; yu are the victim f identify theft and place a fraud alert in yur file; yur file cntains inaccurate infrmatin as a result f fraud; yu are n public assistance; yu are unemplyed but expect t apply fr emplyment within 60 days. In additin, by September 2005 all cnsumers will be entitled t ne free disclsure every 12 mnths upn request frm each natinwide credit bureau and frm natinwide specialty cnsumer reprting agencies. See fr additinal infrmatin. Yu have the right t ask fr a credit scre. Credit scres are numerical summaries f yur credit-wrthiness based n infrmatin frm credit bureaus. Yu may request a credit scre frm cnsumer reprting agencies that create scres r distribute scres used in residential real prperty lans, but yu will have t pay fr it. In sme mrtgage transactins, yu will receive credit scre infrmatin fr free frm the mrtgage lender. Yu have the right t dispute incmplete r inaccurate infrmatin. If yu identify infrmatin in yur file that is incmplete r inaccurate, and reprt it t the cnsumer reprting agency, the agency must investigate unless yur dispute is frivlus. See fr an explanatin f dispute prcedures. Cnsumer reprting agencies must crrect r delete inaccurate, incmplete, r unverifiable infrmatin. Inaccurate, incmplete r unverifiable infrmatin must be remved r crrected, usually within 30 days. Hwever, a cnsumer reprting agency may cntinue t reprt infrmatin it has verified as accurate. Cnsumer reprting agencies may nt reprt utdated negative infrmatin. In mst cases, a cnsumer reprting agency may nt reprt negative infrmatin that is mre than seven years ld, r bankruptcies that are mre than 10 years ld. Access t yur file is limited. A cnsumer reprting agency may prvide infrmatin abut yu nly t peple with a valid need -- usually t cnsider an applicatin with a creditr, insurer, emplyer, landlrd, r ther business. The FCRA specifies thse with a valid need fr access. Yu must give yur cnsent fr reprts t be prvided t emplyers. A cnsumer-reprting agency may nt give ut infrmatin abut yu t yur emplyer, r a ptential emplyer, withut yur written cnsent given t the emplyer. Written cnsent generally is nt required in the trucking industry. Fr mre infrmatin, g t

8 Ntificatin and Release Kerndle Clinic Yu may limit prescreened ffers f credit and insurance yu get based n infrmatin in yur credit reprt. Unslicited prescreened ffers fr credit and insurance must include a tll-free phne number yu can call if yu chse t remve yur name and address frm the lists these ffers are based n. Yu may pt-ut with the natinwide credit bureaus at OPTOUT ( ). Yu may seek damages frm vilatrs. If a cnsumer reprting agency, r, in sme cases, a user f cnsumer reprts r a furnisher f infrmatin t a cnsumer reprting agency vilates the FCRA, yu may be able t sue in state r federal curt. Identity theft victims and active duty military persnnel have additinal rights. Fr mre infrmatin, visit States may enfrce the FCRA, and many states have their wn cnsumer reprting laws. In sme cases, yu may have mre rights under state law. Fr mre infrmatin, cntact yur state r lcal cnsumer prtectin agency r yur state Attrney General. Federal enfrcers are: FOR QUESTIONS OR CONCERNS REGARDING Cnsumer reprting agencies, creditrs and thers nt listed belw Natinal banks, federal branches/agencies f freign banks (wrd Natinal r initials N.A. appear in r after bank s name) Federal Reserve System member banks (except natinal banks, and federal branches/agencies f freign banks) Savings assciatins and federally chartered savings banks (wrd Federal r initials F.S.B. appear in federal institutin s name) Federal credit unins (wrds Federal Credit Unin appear in institutin s name) State-chartered banks that are nt members f the Federal Reserve System Air, surface, r rail cmmn carriers regulated by frmer Civil Aernautics Bard r Interstate Cmmerce Cmmissin Activities subject t the Packers and Stckyards Act, 1921 PLEASE CONTACT Federal Trade Cmmissin Cnsumer Respnse Center- FCRA Washingtn, DC Office f the Cmptrller f the Currency Cmpliance Management, Mail Stp 6-6 Washingtn, DC Federal Reserve Bard Divisin f Cnsumer & Cmmunity Affairs Washingtn, DC Office f Thrift Supervisin Cnsumer Prgrams Washingtn D.C Natinal Credit Unin Administratin 1775 Duke Street Alexandria, VA Federal Depsit Insurance Crpratin Divisin f Cmpliance & Cnsumer Affairs Washingtn, DC Department f Transprtatin Office f Financial Management Washingtn, DC Department f Agriculture Office f Deputy Administratr-GIPSA Washingtn, DC