Authorization For Consumer and/or Investigative Report
(Important: Please read carefully before signing authorization)
CA, MN, OK Only
I understand that if the above named employer requests a copy of my consumer report for employment purposes,
I have the right under California, NMinnestota, and Oklahmoa law to recieve a copy of that comsuer report
from the employer free of charge. I understnad that buy checking yes below, a copy will be provided to
me at the address I provieded above, I would like to recieva copy of my comuter report
The company may request consumer reports or investigative consumer reports in connection with your application
for employement (if any) with the company. Any information contained in such reports may be taken into
consideration in evaluating your suitabliity for employment, promotion, reassignment or rentention as an employee.
Such reports, if obtainted, will be prepared by a consumer reporting agency and may contain information concerning
your credit standing or worthiness, character, general reputation, personal characteristics, or mode of living.
The types of reports that may be requested, include, but are not limited to: credit reports, criminal records
checks, court records checks, and/or summaries of educational and employment records and histories. The
information contained in such reports may be obtained from public record sources or through personal interviews
with your neihgbors, friends, associates, current or former employers, or other personal acquaintances.
I certify that the information contained in this application is true and correct and complete to the best of my knowledge
and belief. I understand that any false statement, omissions or misrepresentation of facts in connection with this
application can be cause for rejection of my application, or if I am employed, for my dismissal from employment.
I also understand that I am required to abide by all rules and regulations of the Employer.
I hereby understand and acknowledge that if I am employed, my employment relationship with the Employer is of an "at will"
nature, which means that I may resign at any time and the Employer may discharge me at any time, with or without cause.
It is futher understood that this "at will" employment relationship may not be changed by any statement or conduct of any
person, unless such change is specifically achnowledged in writing, signed by the Administrator of the Employer.
I achnowledge that no other promises, agreements or representations have been made contrary to this "at will" employment
agreement, and that this agreement, as acknoweldged by my signature below, is the full and comnplete agreement governing
the Employer's rights and obligations concerning the termination of my employment.
Signature of Applicant (enter your name, a signature will be requested in person)
Applications will be maintained in an active file for a period of one year and then transferred to an inactive
status for a period of one year from date received.
We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, sexual orientation,
marital or veteran status, physical or mental disabilities, or any other legally protected status.
Employment Physical Notification
I, , understand that Meadowood Nursing Center requires an employment physical,
which includes drug testing. This examination will be at the company's expense with the test results being conficential.
Furthermore, I agree that the attending physician will norify the designated company representative if I pass or fail the examination.
The company, in turn, will hold this information in strict conficence and it will be for company use only.
Any offer of employment is subject to and contingent upon my successfully passing this employment physical.
Health Care Provider:
Physician: Dr. R.D. Jennings
Address: 15230 Lakeshore Dr.
City: Clearlake, CA 95422
Telephone Number: 707-994-4500
If I do not pass the physical, I have the right to request information concerning the reasons I did not pass the medical examination.
Such request should be directed to the health care provider who performed the medical examination.
Applicant's Signature (enter your name, a signature will be requested in person)
Your social security number is required, but is not requested here for security reasons.
Your social security number will be requested in person after this application has been received.