POSITION APPLIED FOR:

APPLICANT INFORMATION

Availability

What hours are you available to work?

Driving

If yes, please provide the following:

PROFESSIONAL REFERENCES

Please list two, other than past employers or relatives

Reference 1

Reference 2

EDUCATION

High School/G.E.D.

College/Vocational

Graduate

Professional Licenses/Registrations Held

WORK EXPERIENCE

Employer 1

Employment Dates

Employer 2

Employment Dates

Employer 3

Employment Dates

I certify that to the best of my knowledge, information included on this application is true and accurate. I understand all information on this application may be verified by LifeCare Alliance or its agent and that false statements or omissions will be considered grounds for immediate termination. I acknowledge that if employed, my employment can be terminated at any time, with or without cause or notice, by LifeCare Alliance or myself. I understand that no representative of LifeCare Alliance has any authority to enter into any agreement for employment for a specified period of time or to assume any benefits or terms and conditions of employment accept the CEO/President of LifeCare Alliance and he/she may only do so in writing. By signing, I acknowledge that I have read, understand, and agree to the above statements.

Employment Application Addendum

Ohio State laws require this agency to conduct criminal background investigations on all employees. Attached you will find a list of all offenses which may disqualify you from being considered for this position. Please review this list and report any pleas or convictions, and dates of these crimes. If you have no conviction or pleas, write “none”.

You are required to list only pleas to or convictions of crimes listed on the attached pages, or similar crimes committed in another state or country. Do not report arrests, only convictions. Listing an offense will not automatically disqualify you from a position. We will consider the nature of the crime, the number of pleas or convictions, and the date of the plea or conviction.

This application addendum is not a substitute for a criminal investigation conducted by the Ohio Bureau of Criminal Identification and Investigation (BCII) or the FBI. If you accept a position at LifeCare Alliance, you will be fingerprinted, and your prints will be sent to BCII for screening. The agency will pay for this screening.

If you are found to have plead to or been convicted of any of the listed crimes, you may be subject to discharge from employment, depending upon the type of crime, circumstances under which it occurred, and time passed since the last such plea or conviction. If you fail to fully disclose on this form, and we learn from the BCII report, or in any other way, that you have failed to disclose, your employment will be terminated.

NOTE: A criminal record that has been sealed or expunged must also be disclosed if the activity was one or more of the listed crimes.

Applicant Consent Form

Disclosure Under Fair Credit Reporting Act and Consent to Procurement of Consumer Report for Employment Purposes

The undersigned hereby authorizes that LifeCare Alliance, or its insurance agency, Willis Towers Watson, or it assigns to obtain copies of consumer reports, including a motor vehicle report, pertaining to me for employment purposes and use in rating and/or underwriting insurance for which the above named employer may apply and any renewal thereof. I understand that in obtaining such consumer reports, a consumer reporting agency may be used and I do hereby authorize such use.

Reference Check Release Form

Request for Extension

Applicant Information

LifeCare Alliance requests the information below in order to assist our equal employment opportunity efforts. The information is voluntary and will in no way affect the processing of your application or consideration for employment.

This form is kept confidential and is not retained with your application. Information provided is used only in accordance with the law, our affirmative action program and other equal employment opportunity purposes.