Application for Employment

Date of Application:

If we may contact      you at work:      Phone:

Are you legally eligible for employment in this country? 

Yes No  

Proof of U.S. citizenship or immigration status will be required upon employment.

Yes No  

Have you ever been convicted of a crime or pled guilty or no contest to a felony, misdemeanor, or any offense other than a minor traffic violation (whether in state or federal court)?

Are any criminal charges now pending against you?

Yes No  

Please be advised that if you are hired, we will require you to undergo a criminal background check.  Your conviction history WILL NOT necessarily disqualify you from consideration for employment.

List your last three (3) employers, assignments, or volunteer activities, starting with the most recent, including military experience.  Explain any gaps in employment in the Comments section below.

Comments (including explanation of any gaps in employment):

Skills and Qualifications: 

A.  List last three (3) schools attended, starting with the most recent.  B.  List number of years completed.  C.  Indicate what degree or diploma was earned, if any.  D.  Indicate major and minor fields of study (if applicable).

List professional, trade, business, or civic associations and any offices held which you would like to share with Fayette Companies.  
(Exclude memberships that would reveal sex, race, religion, national origin, age, color, disability, or other protected status.)

List special accomplishments, publications, and awards which you would like to share with Fayette Companies. 
(Exclude memberships that would reveal sex, race, national origin, age, color, disability, or other protected status.)

List any additional information you would like us to consider.

Response is REQUIRED whether or not you have ever had a professional license.

Have you ever had any clinical privileges or your professional license suspended or revoked, or are any professional registration, licensure, or certification actions now pending against you?

Yes No  

Has any sanction other than suspension or revocation been imposed on you by any licensing agency?

Yes No  

Have you ever voluntarily surrendered a professional license?

Yes No  

Have you ever been excluded from participation as a provider by Medicare or Medicaid?

Yes No  

Have you or any health care provider associated with you been the subject of a Corporate Integrity Agreement imposed by the department of Health and Human Services?

Yes No  

Have you or any health care provider associated with you been a party to either as a plaintiff or as a defendant) any civil OR criminal litigation involving an allegation of filing false or inaccurate claims with any health insurance carrier?  Litigation includes so-called Qui Tam suits, civil false claims suits, and suits to secure recoupment or repayment of insurance overpayments?

Yes No  

Are you aware of any possible or threatened action against you involving any professional license you hold, affecting your right to future participation in Medicare or Medicaid?

Yes No  

Have any professional liability claims or lawsuits been filed against you during the past five years?

Yes No  

Have you ever been accused of sexual misconduct/impropriety or engaged in any sexual activity with a client/patient?

Yes No  

Fayette Companies holds its employees to high standards of conduct with all individuals.  If employed, will you comply with our professional ethics policy, our code of conduct, and our policy against sexual harassment and other forms of illegal harassment?

Yes No  

Please Read Carefully Before Accepting

If you have any questions regarding the following statements, please ask them of the Human Resources Department.

It is understood and agreed upon that any falsehood of misrepresentation by me in this application may result in the cancellation of this application and/or separation from the employer's services if I have been employed.  Furthermore, I understand that just as I am free to resign at any time, Fayette Companies (and subsidiaries) reserves the right to terminate my employment at any time, with or without prior notice.  I understand that no representative of Fayette Companies, other than an authorized officer, has the authority to make any assurances to the contrary.  I understand that receipt of this application by Fayette Companies does not imply that I will be offered employment.  This application does not constitute an agreement or contract for employment for any specified period or definite duration.

I give Fayette Companies the right to investigate all references and to secure additional information about me in order to arrive at a hiring decision.  I also authorize all persons, institutions, organizations, and companies to furnish any and all requested information, and waive any legal requirement to provide notice to me regarding reports, records, or information given or received in accordance with this authorization.

I hereby release and hold harmless Fayette Companies, its agents, employees, and assigns from any claims of liability I may have against them arising out of those reviews and checks.

I further hereby authorize any person or entity to whom this authorization is presented to release any information in his/her possession to Fayette Companies, its agents, employees, or assigns.  I further agree to release and hold harmless any person or entity from any claims of liability I may have against him/her/it for the release of such information.

Fayette Companies is an Equal Opportunity Employer.  Fayette Companies does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state, or federal law.

This application is current for only 60 days.  At the conclusion of this time, if I  have not heard from Fayette Companies and still wish to be considered for employment, it may be necessary to complete a new application.  Contact the Human Resources Department to determine the current status of your application.

I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.

I hereby acknowledge that I have read and understood each of the above statements.

Note: Denying Authorization will nullify this application and cannot be accepted for employment