Days and times that you are available to commit to a work schedule:
Include individuals directly familiar with your work ability. Please include one close relative. Use phone numbers where references may be reached during weekdays.
Certification and Release
I certify that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize SLI and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to a drug test to detect the use of illegal drugs prior to and during my employment. I understand that all offers of employment will be conditional offers of employment subject to passage of a drug screen, DCF CPS/APS, KDHE and DMV. If I am unable to pass a drug screen DCF CPS/APS, KDHE ot DMV. SLI reserves the right to withdraw the conditional offer of employment whether or not employment has actually begun.
This release is valid for 12 months following date of release.
SLI does not discriminate on the basis of race, color, religion, nation of origin, ancestry, sex, age, disability or veteran status. Our organization highly values diversity. Inquiries concerning our organization's compliance with equal rights regulations should be directed to the Vice President of Services and Faciliites.
SLI Applicant Authorization to Release Information
I authorize SLI to contact any company, institution, law enforcement agency, state agency, bureau or individual it deems appropriate to investigate my employment history, job performance, background, qualifications, driving record and other relevant information, if job related. I give my full consent for all contacted persons, including former employers, to provide the information concerning this application, I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to the Company.
SLI currently verifies information with:
- Kansas Bureau of Investigation
- KDADS Nurse Aide Registry
- Adult and Child Abuse and Neglect - Department for Children and Families
- Motor Vehicle Report
- Topeka Municipal Court
- KDADS Health Occupations Credentialing
- Office of Inspector General
- Shawnee County Court Records
- KDOC Kansas Adult Supervised Population Electronic Repository
- Other local, state and national databases and public information systems
According to the Fair Credit Reporting Act, applicants are entitled to know if insurance or employment is denied because of information obtained by the prospective employer from a consumer-reporting agency.