Personal Information |
| Are you legally eligible for U.S. Employment? |
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| Have you ever been discharged or asked to resign from a job?
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| Do you possess a valid driver's license? |
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| If yes, please provide state of issue: |
State:
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| Has your driver's license ever been suspended or revoked? |
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To your knowledge, are you listed on CMS's "List of
Excluded Individuals/Entities" as someone who is excluded
from participation in Medicare/Medicaid/Medi-Cal or any
other federally funded health care programs?
(
LightBridge Hospice will not hire or continue employment of those
individuals
who
are in
the database and are currently excluded from Medicare program participation.) |
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| Can you meet the attendance requirements of the job? |
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Have you ever been convicted of a felony?
If yes, please explain the conviction. (A conviction will not necessarily disqualify
you from employment.) Exclude convictions for marijuana-related offenses for
personal use that
are more than two years old; convictions that have been sealed,
expunged, or legally eradicated; and misdemeanor convictions for which probation
was completed and
the case was judicially dismissed pursuant to the Penal Code
Section
1203.4.
You may also exclude minor traffic violations. Drunk or reckless
driving is not considered to be minor.
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Have you ever had a license to provide
health care revoked, limited,
modified, suspended? |
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| Have you ever had any criminal conviction relating to: |
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Any federal health care program including
Medicare and Medicaid/Medi-Cal? |
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Patient neglect or abuse? |
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Health care fraud? |
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Use of controlled substances? |
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Fraud, theft, embezzlement? |
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Breach of fiduciary responsibility or other financial misconduct? |
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Obstruction to a health care investigation? |
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Any criminal offense involving violence or assault? |
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| Please list any friends or family members currently employed by LightBridge Hospice: |
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It is the policy of LightBridge Hospice to check an employee's Department of Motor
Vehicle's driving record
upon hire and on an annual basis. An individual will not be eligible for hire or continued employment if they: |
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• Have had more then three (3) moving violations or more than one chargeable accident in the past thirty-six (36) months. |
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• Have had a major conviction (driving under the influence of alcohol or drugs) within the past seven (7) years. |
Please Read
The facts set forth in my application for employment are true and complete. I understand that if employed, false statements
or omissions on this application will usually result in termination of employment. I understand that an offer of employment
is contingent upon satisfactory proof of lawful employment status as set forth in the Immigration Reform and Control Act.
Permission is hereby given to the Company to investigate previous employment, educational background and references.
I release the Company and former employers from any liability resulting from any lawful information provided which may
result in withdrawal of an employment offer or termination. I also understand that I am not eligible for employment with
LightBridge if I am at any time, subject to exclusion from participating in any federally funded health care program.
I understand that the Company has a policy prohibiting conflicts of interest or improper use of proprietary information
which prohibits any release or use of Company property that would interfere with the business interests or operations
of the Company. I understand that employment with the Company is at will and may be terminated at any time by either
the Company or myself with or without cause.
By typing my Social Security Number above, and the following code, I hereby certify to the best of my
knowledge that the information I have provided above is accurate and true. |
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