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If you are not a U.S. Citizen, are you legally authorized to work in the U.S.?
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(If hired, you will be required to provide proof of your legal right to work)
Have you ever been sanctioned or disciplined by any state or federal authority or excluded from participation in the Medicare or Medi-Cal programs under Sec. 1128 of the Social Security Act?
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hree former supervisors, managers or teachers other than relatives.
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Inland Home Health Providers, Inc. (IHHP) is committed to a policy of equal employment opportunity and considers all persons without regard to race, color, religion, age, sex, national origin, disability, marital status, veteran’s status, or any other legally protected classification as defined by city, state, and federal law.
Certification and Acknowledgment (Please read carefully and sign)
I certify that all of the information I have provided on this application and on any accompanying documents is true
and correct. I understand that any false statements I have made herein on my failure to disclose requested information
may disqualify me from consideration for employment or if employed may result in my termination.
I hereby authorize IHHP, its agents and employees to contact any reference provided by me during the application
process, and I authorize all references all so contacted to release any information about me that they may have. I
further authorize IHHP or its agents to perform an investigation of local, state and federal records relating to any
criminal conviction I may have. I release IHHP, its agents, officers and employees and any reference contacted by
IHHP from any and all liability that may result from any investigation or reference check.
I understand and acknowledge that I may be required to undergo a post-offer, pre-employment physical exam, and a
post-offer, pre-placement drug screening and analysis for substance abuse. I understand that the result may to the
extent permitted by law, result in the revocation of any offer of employment.
I understand and acknowledge that nothing contained in this application or in any interview which I may be granted i
s intended to create a contract of employment between IHHP and me. I further understand and acknowledge that if I
am offered employment, I am free to terminate my employment at any time, for any reason, and the company retains
the same right.
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