* = Required Information
Male Female Other

This does not count against you. We use this to choose the best location for you.

CNA

GNA

LPN

RN

HHA

Other
Yes No
Yes No
Yes No
Yes No

Education

Yes No
Yes No

Training

I have all the required documents listed on this application. *

Employment Experience (begin with most recent position)

Dates of Employment

Dates of Employment

Dates of Employment

References

Please provide names of two people who can provide us with the reference, past employer and someone who is not related to you

Consent to Request and Authorization to Reveal Information About Employment History

As part of my application for contractual employment with SRHCS. I consent that SRHCS may request from any of my former employers all information that SRHCS may need concerning me, my skills, or my work performance. I correspondingly authorize all my former employers to reveal all information to SRHCS upon request.

EMPLOYMENT BACKGROUND INVESTIGATION AUTHORISATION

  1. I Understand that an investigative report may be generated on me that may include information as to my character, work habits, performance and experience, along with reasons for termination of past employment, financial credit history, criminal history records from any criminal justice agency in any federal, state, city and county jurisdictions, state Department of Motor Vehicle/Drives' License Records to include traffic citations and registration, military records from National Personnel Record Center, education records including transcript and requests for records and information from any individual, company, firm corporation, present and/pr past employers and public agencies (including the Social Security Administration and Immigration and Naturalization Service). I fully understand that Solid Rock Health Care Services and their Agent may be requesting information from public and private sources about any information noted earlier in this paragraph, and I freely give my consent for Solid Rock Health Care Services and their agent.
  2. According to the Fair Credit Reporting Act (FCRA), I am entitled to know if the considerations for which I am Applying are denied because of information obtained from a Consumer Reporting Agency. If so, I will be notified and given the names of the agency proving that report.
  3. I agree that a photocopy or telephone facsimile of this authorization shall be valid as the original. This release is valid for most federal, state or country agencies.
  4. I hereby authorize, without reservation, any one contacted by Solid Rock Health Care Services and or their agent, to provide the information requested in section I
  5. I hereby authorize, without reservation, Solid Rock Health Care Services and or their agent, to contact my present employer for employment verification and references.

CONFIDENTIALITY AGREEMENT

The nature of services provided by SRHCS requires information to be handled in a private, confidential manner. Information about our business or our employees or clients will only be released to people or agencies outside SRHCS with our written consent. Following legal or regulatory guidelines can provide the only exceptions to this policy. All reports, memoranda, notes, or other documents will remain part of SRHCS confidential records.

The names, addresses, phone numbers or salaries of our employees will only be released to people authorized by the nature of their duties to receive such information and only with the consent of management or the contractual employees.

The undersigned Applicant agrees to abide by this confidentiality agreement.