APPLICATION FOR EMPLOYMENT
Hickory Ridge
Applicant Notice: You are applying for employment with the above listed Facility. To be eligible for employment, you must
read and agree to the following ‘conditions of employment;’ then sign below.
THIS IS A DRUG-FREE WORKPLACE
ANY PERSON EMPLOYED BY THIS FACILITY SHALL BE SUBJECT TO RANDOM DRUG OR ALCOHOL TESTING AT ANY TIME AND AT THE FACILITY’S
DISCRETION.
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POST- EMPLOYMENT PHYSICAL
THIS FACILITY REQUIRES ALL EMPLOYEES TO HAVE A MEDICAL EXAMINATION. AFTER AN EMPLOYMENT OFFER HAS BEEN MADE TO A JOB APPLICANT
AND BEFORE THE APPLICANT BEGINS THEIR EMPLOYMENT DUTIES, THEY MUST HAVE A MEDICAL EXAMINATION.
ALL OFFERS OF EMPLOYMENT ARE MADE CONTINGENT ON THE MEDICAL EXAMINATION RESULTS. THE SUCCESSFUL
APPLICANT MUST BE QUALIFIED AND MUST BE ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITION THEY
HAVE APPLIED FOR, WITH OR WITHOUT REASONABLE ACCOMMODATIONS.
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CRIMINAL RECORD’S CHECK
TO BE ELIGIBLE FOR EMPLOYMENT WITH THIS FACILITY, EVERY EMPLOYEE WILL BE CHECKED AGAINST THE OIG
EXCLUSION CHECKLIST (PRE-EMPLOYMENT and PERIODICALLY POST-EMPLOYMENT). EVERY EMPLOYEE MUST SUBMIT
TO A CRIMINAL RECORDS CHECK WITHIN 5 DAYS OF EMPLOYMENT.
WHEN EMPLOYED, THE APPLICANT WILL BE CHARGED $22.00 FOR THE COST OF THE BCI&I (Ohio Bureau of
Criminal Identification and Investigation) CRIMINAL RECORDS’ CHECK. IF THE EMPLOYEE-APPLICANT HAS
NOT BEEN A RESIDENT OF OHIO FOR MORE THAN 5 YEARS, THEY WILL ALSO BE CHARGED $29.00 FOR THE COST
OF THE FBI (Federal Bureau of Investigation) CRIMINAL RECORDS CHECK.
THE COST OF THE RECORDS CHECK SHALL BE DEDUCTED FROM THE EMPLOYEE’S FIRST PAYCHECK, THROUGH A PAYROLL
DEDUCTION. BECAUSE THIS IS A ‘CONDITION OF EMPLOYMENT,’ AN APPLICANT WILL NOT BE CONSIDERED FOR EMPLOYMENT
WITHOUT THEIR AGREEMENT TO PAY FOR THE REQUIRED CRIMINAL RECORDS’ CHECK. (Your signature is required
below.)
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I have read and understand the above listed requirements. I understand my employment with the Facility
is “at will” and is contingent upon the successful passage of my criminal background check, past
employment references and my post-employment medical examination.
With my signature, I certify that I currently not under investigation for or been convicted of a
crime that may exclude me from employment in a nursing facility. I also understand that a criminal
records check is a condition of employment and that I will be responsible for the cost of said records’
check. I HEREBY APPROVE the deduction of the associated cost of said records check(s) from my paycheck.
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