I acknowledge that consideration for employment is contingent on the results of a reference and background check. Therefore, I hereby authorize this company to (1) investigate the truthfulness of all statements made on this application; (2) contact my current/former employer(s) and other listed references or any other persons who can verify information; (3) discuss the results of any investigation with other employees of this company involved in the hiring process; and (4) check my criminal record. In addition, I give my consent for all contacted persons including current/former employer(s) to provide the information concerning this application, and I release each such person from any liability for providing this information to this company.
I certify that the information contained in this application is correct to the best of my knowledge, and understand that falsification of this application in any detail is grounds for disqualification from further consideration or dismissal from employment in accordance with company policy. If I am accepted for employment with this company, I agree to abide by its personnel policies and also
report to either my supervisor, the main of ice, or the 24 hour answering service regarding any and all job related accidents, injuries, and /or illnesses within twenty four(24) hours of their occurrence, regardless of the severity. I understand this company does not subscribe to workman’s compensation insurance, therefore if an incident or accident occurs on the job, I must report it to my supervisor or dispatcher within
24 hours. A written report and investigation will be completed and signed by the employee. The findings will be given to the director for claim determination. A full work release must be obtained before returning
to work.
By signing this application I certify that I have not been, and that I am not now excluded from participation in any Federal Health Care Program, or have sanctions placed against my license and medical credentials and if I’m accepted for employment by this agency that I will advise the Human Resources Department immediately upon notification of exclusion from participation in a Federal Health Care program or when advised of the imposition of sanctions. after a conviction of one (1) or more of the offenses listed in subsection (a)(1) commits a Class A infraction.
Any conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for any offense
containing elements that are substantially similar to the elements of an offense listed above
