* = Required Information
General Information
Yes No
Position
Yes No
Education and Training
Yes No

College, Business School, Military (Most recent first)

Dates Attended Month / Year

Yes No

Dates Attended Month / Year

Yes No

Dates Attended Month / Year

Yes No

Dates Attended Month / Year

Yes No



Veteran Information (Most Recent)
Special Skills
Employment Reference
(Most Recent First - Include voluntary work and military experience)
Yes No

Yes No

Yes No

Yes No

I certify the information contained in the application is true, correct, and complete. I understand that, If employed, false statements reported on this application may be considered sufficient cause for dismissal.

Confidential Reference Request

I hereby authorize the facility / institution named below to release all information requested on the confidential reference request.

Dear Sir or Madam:
The above-named applicant has indicated that he/she was previously employed by you. Your evaluation of him/her will be sincerely appreciated, and will be held in complete confidence. Both the applciant and I will benefit from an early reply, since his/her employment is pending. Thank you.

Dates of Employment:

Yes No
Good Adequate Poor
Good Adequate Poor
Good Adequate Poor
Good Adequate Poor
Good Adequate Poor
Consumer Report Disclosure and Consent

DISCLOSURE
[For use by all except those residing or seeking employment in Oklahoma, Minnesota or California]

In connection with your employment or application for employment (including contracted services), at New Lanark Healthcare, Inc. consumer reports and investigative consumer reports may be requested frm MESH, a consumer reporting agency. These reports may include the following types of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, academic history, professional credentials, and druges/alcohol use. SUch reports may contain public record information concerning your driving record, worker's compensation claims, credit, bankcruptcy proceedings, criminal records, etc., from federal, state, and other agencies which maintain such records; as well as information from MESH concerning previous driving record< requests made by others from such state agencies and state provided driving records. Investigate consumer reports may cinclude information as to your character, general reputation, personal characteristics and mode of living.

You have the right to contact MESH, upon proper identification, to request, in wiriting, the nature and substance of all information in its files on you at the time of your request, including the sources of information and the recipients of any reports on you that MESH has previously furnished within the two-year period preceding your request. MESH may be contacted by:
○    Mail: PO Box 343, Berkeley Heights, NJ 07922
○    EMail: ConsumerReport@Go2Mesh.com
○    Phone: (888) 988-MESH
A "Summary of Consumer Rights" documents is accompanied as erquired under the Fair Credit Reporting Act [609.c3]

CONSENT

I authorize, without reservations, MESH, and any party or agency contacted by MESH, to furnish the above=mentioned information for employment purposes, including hiring and promotion considerations at the company.

MESH is authorized to disclose all information obtained to New Lanark Healthcare, Inc. for the purpose of making a determination as to my eligibility for employment, promotion, reassignment or retention as an employee, or any other lawful purpose. If hired or contracted by New Lanark Healthcare, Inc., this consent and authorization shall remain on file and shall serve as ongoing consent and authorization for the procurement of consumer reports at any time during my employment or contract period.
By signing below, I certify that I have read and fully understand this release, that prior to signing I was given the opportunity to ask questions and to have those questions answered to my satisfaction, and that I executed this release voluntary and with the knowledge that the information being released could affect my being hired, my employment, or my eligibility for promotion.

NOTE: The following need only be completed at the request of New Lanark Healthcare, Inc. to facilitate the background checking process.

Yes No
Government Forms
Physician Examination Report

To be completed by employees physician:

The above named person has been offered employment, or is currently employed by New Lanark Healthcare, Inc. Agency. It is our company policy, in accordance with Federal and State regulations to require a physical examination for all of our health core workers. We would appreciate you completing the following information. Thank you.

I hereby authorize the release of information below to New Lanark Healthcare Services .

Female Male
Yes No

Please indicate dates and findings of the following:

(If vaccine not given, complete the following:)

Rubella Titre

Rubella Vaccine

Rubeola Titre

Rubeola Vaccine

Varicella Titre

#1 PPD (If 31 PPD Negative, must have #2 PPD within 1-3 weeks)

0 mm 1-4 mm 5-9 mm 10-15 mm
Over 15 mm

#2 PPD

0 mm 1-4 mm 5-9 mm

*If positive PPD must have Chest X-Ray:

Drug Screen

Negative Positive
Declined Contraindicated
Yes No

This applciant was interviewd and examinated by me. I found his/her health status adequate for work in the healthcare field.

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