Application for Employment

Equal access to programs, services and employment is available to all persons. Those applicants requiring a reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department. We are an equal opportunity employer.

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Name:

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Address:

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Note: This question is not designed to elicit information about an applicant's disability. Please do not provide information about the existence of a disability, particular accommodation, or whether accommodation is necessary. These issues may be addressed at a later stage, to the extent permitted by law.

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Note: Answering "yes" to the following question does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

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Employment Experience

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Employer One

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Dates employed:

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Employer Two

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Dates employed:

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Employer Three

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Dates employed:

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Employment Experience (continued)

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Education Background

High School

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College

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Graduate School

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Vocational Training/Other

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High School

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College

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Graduate School

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Vocational Training/Other

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References

NOTE: List names and telephone numbers of three business/work references who are not related to you and are not previous supervisors. If not applicable, list three school or personal references who are not related to you.

Reference 1:

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Reference 2:

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Reference 3:

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Voluntary Disclosure

 

Individuals seeking employment are considered without regard to race, color, religion, creed, sex, age, national origin, citizenship status, disability status, sexual orientation, gender identity or expression, pregnancy, genetic information, protected military and veteran status, ancestry, marital status, medical condition (cancer and genetic characteristics) or any other characteristic protected by law. You are being given the opportunity to provide the following information in order to help us comply with federal and state Equal Employment Opportunity/Affirmative Action record keeping, reporting, and other legal requirements.

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Privacy

 

I explicitly and unambiguously consent to the collection, use or transfer in electronic or other form, of my Personal Data to Case Medical and its Affiliates, or any third parties (“Recipients”) assisting in the recruitment activities.  “Personal data” includes, but is not limited to, name, home address, telephone number, date of birth, salary information, job title.  “Recruitment activities” includes the activities associated with a job seeker application and Case Medical's review and decision making regarding the application. 

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Voluntary Self-Identification of Disability

 

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Why are you being asked to complete this form?

 

We are a federal contractor or subcontractor required by law to provide equal employment opportunity to qualified people with disabilities. To do this, we must ask applicants and employees if they have a disability or have ever had a disability.  

Identifying yourself as an individual with a disability is voluntary, and we hope that you will choose to do so. Your answer will be maintained confidentially and not be seen by officials or anyone else involved in making personnel decisions. Completing the form will not negatively impact you in any way, regardless of whether you have self-identified in the past. For more information about this form or the equal employment obligations of federal contractors under Section 503 of the Rehabilitation Act, visit the U.S. Department of Labor’s Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp.

How do you know if you have a disability?

 

You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:

• Autism
• Autoimmune disorder, for example, lupus, fibromyalgia, rheumatoid arthritis, or HIV/AIDS
• Blind or low vision
• Cancer
• Cardiovascular or heart disease
• Celiac disease
• Cerebral palsy
• Deaf or hard of hearing
• Depression or anxiety
• Diabetes
• Epilepsy
• Gastrointestinal disorders, for example, Crohn's Disease, or irritable bowel syndrome
• Intellectual disability
• Missing limbs or partially missing limbs
• Nervous system condition for example, migraine headaches, Parkinson's disease, or Multiple sclerosis (MS)
• Psychiatric condition, for example, bipolar disorder, schizophrenia, PTSD, or major depression

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 Applicant Statement

 

I certify that all the information submitted by me on this application is true and complete, and I understand that if any false or misleading information, omissions or misrepresentations are discovered, my application may be rejected, and if I am employed, my employment may be terminated at any time.

If hired, I agree to conform to the Company's rules and regulations, and I understand that these rules and/or the employee handbook do not form a contract of employment either express or implied, and I agree that my employment and compensation can be terminated, with or without cause and with or without notice, at any time, at either my or the Company's option.

I also understand and agree that the terms and conditions of my employment may be changed, with or without cause and with or without notice, at any time by the Company. I understand that no Company representative, other than its CEO, and then only when in writing and signed by the CEO, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing. 

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives for seeking, gathering and using truthful  and  nondefamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that this application remains for only 60 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary for me to reapply and fill out a new application.

I also understand that, if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States as required by federal immigration laws.

This company does not tolerate unlawful discrimination or harassment based on sex, race, color, religion, national origin, citizenship, age, disability, or any other protected status under applicable federal, state or local law. No question on this application is used to limit or exclude an applicant from employment consideration on any basis prohibited by applicable federal, state or local law.

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