Rev Jan/2017

APPLICATION FOR EMPLOYMENT The Sisters of Charity of Cincinnati complies with the Federal and State EEOC/OCRC regulations and employment related laws (as

amended) by providing equal employment opportunity for all employees and applicants regardless of, but not limited to, race, color,

religion, sex, age, national origin, citizenship status, disability, genetic information, or veteran status.

Please print all information necessary for employment consideration.

Incomplete or incorrect information may disqualify you for employment.

Position(s) Applying For: 1)____________________ 2)____________________ 3)___________________

Shift Preferred:

1st 2

nd3

rdFT PT Any

Days/Hours Available: Date Available:________

Salary Expected:_______

Last Name First Middle Date of Application

Street Address Home Telephone

( )

City State Zip Other Telephone (specify)

( )

Would you like to provide an email address?

Are you legally eligible for employment in the United States?

YES NO

Last 4 Digits of Social Security #

Are you at least 18 years of age? YES NO If NO, please list date of birth: ______________________

How did you hear about us? If referred, please indicate by whom?_________________________________

Were you previously employed by Sisters of Charity? YES NO

If yes, list positions and dates of employment.___________________________________________________

Do any of your relatives currently work for Sisters of Charity Motherhouse or Mother Margaret Hall?

YES NO If yes, list name.______________________________________________________

5900 Delhi Road

Mount St. Joseph, Ohio 45051

Please list all job related licenses or certifications which would qualify you for work at Sisters of Charity,

i.e., nursing license.

TYPE NUMBER EXPIRATION DATE

Were you ever convicted of a crime, including DUI/DWI? YES NO ((Do not include arrests)

If YES, give date, location, and offense (Note: A conviction will not necessarily disqualify you from

employment.): _____________________________________________________________________________

Are you currently obliged by any employment contract or agreement which would prohibit your

employment with Sisters of Charity? YES NO

If yes, please explain:_____________________________________________________________________________________

EDUCATION

School

Name and Location of

School Course of Study

Number of

Years

Completed

Did You

Graduate?

Degree or

Diploma

Elementary

Junior

High/Middle

High School

Business/Trade/

Technical

College

Graduate

List other job related experiences, skills, qualifications, scholastic honors or licenses which you feel would

qualify you for work with the Sisters of Charity.

_____________________________________________________________________________

_____________________________________________________________________________

MILITARY SERVICE RECORD

Did you serve in the U.S. Armed Forces? ________ If yes, what Branch? _____________________________

Dates of Duty: From ____________ To ____________ Rank at Discharge ____________________________

EMPLOYMENT HISTORY

List below, beginning with most recent, all present and past employment. Please fill this section out even if you submitted a resume. Add employers not listed on your resume. Failure to complete all requested information including wages and dates of employment may delay or

disqualify you from consideration. Add additional pages if needed.

Company Name Telephone ( )

Address Employed (month and year)

From To

Job Title Supervisor and Title Salary

Starting Ending

Job Responsibilities Reason for Leaving

May we contact this employer?

Yes ________ No________

Company Name Telephone ( )

Address Employed (month and year)

From To

Job Title Supervisor and Title Salary

Starting Ending

Job Responsibilities Reason for Leaving

May we contact this employer?

Yes ________ No________

Company Name Telephone ( )

Address Employed (month and year)

From To

Job Title Supervisor and Title Salary

Starting Ending

Job Responsibilities Reason for Leaving

May we contact this employer?

Yes ________ No________

Company Name Telephone ( )

Address Employed (month and year)

From To

Job Title Supervisor and Title Salary

Starting Ending

Job Responsibilities Reason for Leaving

May we contact this employer?

Yes ________ No________

PLEASE READ CAREFULLY

A Drug Free Workplace

Alcohol and Drug Screening Tests are administered as part of the post offer process

and may occur during employment as specified in the Drug and Alcohol Free Policy.

APPLICANT'S AFFIRMATION I declare the foregoing information to be a truthful and complete statement of facts which, if found false, will result in

refusal of hire or termination of employment whenever such false statement is discovered.

I authorize any agency including but not limited to my former employers, references indicated, law enforcement agencies

and all other sources deemed necessary to release any information necessary to make employment decisions. I release all

parties concerned from any liability arising out of such investigation. I also understand that any offer of employment is

contingent upon the successful completion of a post offer employment physical examination and criminal background

check. I hereby release the Sisters of Charity from any/all liability of whatever kind and nature which, at any time, could

result from obtaining and having an employment decision based on such information.

In consideration of my employment, I agree to comply with the rules and regulations of the Sisters of Charity. I further

understand that neither the policies, rules, regulations of employment nor anything said during the interview process shall be

deemed to constitute the terms of an implied employment contract. I understand that if an offer of employment is made and

accepted that my employment is “at will” meaning my employment and compensation can be terminated with or

without cause, with or without notice, at any time at the discretion of either the Sisters of Charity or myself. I

understand that no representative of the Sisters of Charity other than the President of the Sisters of Charity has any authority

to enter any agreement for employment for any specified period of time, or to make any agreement contrary to the

foregoing, and any such agreement must be in writing, signed by the President.

______________________________________________________ __________________________

Signature Date

Applications are retained on file as required by law.

REFERENCES

Name Occupation Day Phone Number

( )

( )

( )

Applicant Copy - to all applicants, please take this copy for your records

www.consumerfinance.gov/leammore. States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. For infonnation about your federal rights, contact:

TYPE OF BUSINESS: CONTACT: 1.a. Banks, savings associallons, and credit unions wilh total a. Consumer Flnancial Protection Bureauassets of over $10 billion and their affilfates. 1700 G Street,, N.W.

b. Such affiliates that are not banks, savings assoda1Jons, or b. Washington, DC 20552Federal Trade Commtsslon: Consumer Response Center

credit unfons also should fist, fn addition to the Cf PB: 600 Pennsylvania Avenue, N.W.Washington, DC 20580(877) 382-4357

2. To the extent not mduded fn item 1 above: a. Office of the Comptroffer of the CurrencyCustomer Assistance Group

a. National banks, federal savinQ$ associations, and federal 1301 McKinney street. SUite 3450branches and federal agencies of foreign banks Houston, TX no1o-9050

b. State member banks, branches and agencies of foreign b. Federal Reserve consumer Hefp Centerbanks (other than federal branches, federal agencies, and P.O. Box 1200Insured State Branches of Foreign Banks), commercial Mfnneapotls, MN 55480lending companfes owned or controUed by foreign banks, c. FDIC Consumer Response Centerand o,garuzatfons operating under section 25 or 25A of the 1100 Watnut Street. Box# 11Federal Reserve Act Kansas City, MO 64108

c. Nonmember Insured Banks, Insured State Branches of d. National CR!dit Union Adminlstrat!onFore?gn Banks, and insUred state savings assoclalfons Office of Consumer Financial Protection (OCFP)

d. Federal Credit Unfons Division of Consumer Comp6ance PoHcy and OUtreach1ns Duke StreetAlexandria, VA 22314

3. Air carriers Asst. General Counsel for Aviation Enforcement & Proceedfngs Aviation Consumer Protection OMsfon Oep811Jnent of Transportation 1200 New Jersey Avenue, S.E. Washtnaton. DC 20590

4. Creditors Subject to the Surface Transportation Board Offlce of Proceedings, Surface Transportation Board Depar1ment of Transportation 395 E Street. S.W. Washinnton, DC 20423

5. Creditors Subm to the Packers and Stockvards Act 1921 Nearest Packers and� · Admfnlsbatfon area suD81Vfsor6. Small Business Investment Companfes Associate Deputy Adm!mstrator for capital Access

United States Small Business Admfnfstration 409 Thi1'd Street, S.W., Suite 8200 Washinaton. DC 20416

7. Brokers and Oeafers Securftfes and Exchange Commission 100 F Street. N.E. Washtnoton. DC 20549

8. Federal Land Banks, Federal land Bank Associations, Fann crecrit Administration Federal lntennedfale Credit Banks, and Production Credit 1501 Farm Credit Drive Assocla1fons Mclean, VA 22102-5090

9. Retailers, F'mance Companies, and All Other Creditors Not Federal Trade Commission! Consumer Response center Listed Above 600 Pennsylvania Avenue, N.W.

Washfngton, DC 20580 (Bm3824357

BACKGROUND CHECK DISCLOSURE DOCUMENT

Sisters of Charity of Cincinnati, Inc. (the "Company .. ) may order a "consumer report" (a background report) about you from a consumer reporting agency (CRA) in connection with your employment or your application for employment (including independent contractor or volunteer assignments, as applicable).

The consumer report may include information about your credit worthiness, credit standing, credit capacity, character. general reputation, personal characteristics, or mode of living. The Company may not order a consumer report about you without your written authorization (which you may provide through a separate document called the Authorization for Background Checks).

The Company may also request an "investigative consumer report .. on you. An "investigative consumer report" is a type of consumer report that involves personal interviews conducted for the Company by the CRA, most commonly with an individual'sprioremployersorreferences.

You have the right to request more information about the nature and scope of any investigative consumer report obtained on you by contacting the Company.

Additionally, the Fair Credit Reporting Act gives you specific rights in dealing with CRAs. You will find these rights summarized in a separate document titled A summary of Your Bights Under the fajr Credjt Reportjng Act.

AUTHORIZATION FOR BACKGROUND CHECKS

I authorize Sisters of Charity of Cincinnati, Inc. (the "Company") to obtain a consumer report {s)(or background

report(s)) on me, including any investigative consumer report s. I also agree that a copy of this form is valid like the signed original.

The consumer reporting agency (CRA) ADP Screening and Select ion Services, Inc. (ADP SASS) w ill prepare the background report for the Company. ADP SASS is located at 30 I Remington Street, Fort Collins, CO, 80 524, and

. can be reached by phone at 800-367-5933 or at www.adpselect.com.

I understand that, as allowed by applicable law, the Company may rely on this authorization to order additional background reports, including investigative consumer reports, (1) during my employment or time as a volunteer or independent contractor, as applicable and (2) from any CRA other than ADP SASS without asking me for my authorization again. I understand the Company may order background report(s) under my legal name and any other names I may have used.

I also authorize the following persons, agencies, and entities to disclose to ADP SASS and its agents all information about or concerning me, as allowed by law, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; if applicable, worker' s compensation injuries; all other private and public sector repositories of information; and any other person, organization, or agency with any information about or concerning me. As allowed by law, such disclosures may contain the following information pertaining to you: credit history; public records; a Social Security number verification; driving records; military service; credentials/ certifications; and verification of prior employment and education

If you live orwork for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free

Please print your legal name:

Last Name ________________ First _____________ Middle ___ _

Signature ________________ _ Date ____ / '-----