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    Application For Employment

    We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation,

    Incomplete applications will not be considered. This company will use the or any other legally protected status. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.

    Instructions To Applicant

    A. Please fully and accurately complete the application for employment and the Information given in the application to verify your previous employment and background.

    B. The application for employment will be considered inactive after 90 days. If you wish to be considered after that time, you must complete a new application for employment.

    C. Resume will not be accepted in lieu of completed applications but will be considered supplemental information.

    D. If you are hired, proof of eligibility will be required to verify your lawful right to work in the United States. (Form I – 9 Work Eligibility)

    Part A: Personal Information

    PART B: EDUCATION AND TRAINING

    J Heart Healthcare

    PART C: PRESENT AND PAST WORK HISTORY

    PART D: WORK HISTORY

    J Heart Healthcare

    PART E: SUPPORTING STATEMENT

    Please indicate all relevant experience, skills and work history that relate to the job description of which you have applied. Please print clearly. All illegible entries will not be considered.

    PART F: MEDICAL HISTORY

    PART G: DECLARATION

    By signing below, I,

    on the date of

    Hereby certify that all information included in the above application is true and valid to the best of my knowledge. I also understand that misrepresentation or falsification of the information provided above will result in my immediate disqualification from the selection process and dismissal from any position appointed to by the Agency after discovery.

    Name

    Date

    J Heart Healthcare

    CONFIDENTIAL AGREEMENT

    READ CAREFULLY AND SIGN BELOW IF YOU AGREE TO THESE TERMS OF EMPLOYMENT

    I agree that except at the request and for the benefit of J Heart Healthcare. I will not disclose to anyone or use for my own purposes any of J Heart Healthcare confidential or proprietary information, either during or after my employment. I understand and agree that J Heart Healthcare bidding, costs, pricing and marketing information and techniques, customer names and information, and employee name and information are confidential and proprietary to J Heart Healthcare.

    I certify that this application contains no willful misrepresentation or falsifications and that this information given by me is true and complete to the best of my knowledge and belief. I authorized J Heart Healthcare to contact all sources to verify the information on this application. I understand that any falsification, misrepresentation, or fraudulent information provided by me in connection with my application for employment is sufficient grounds for withdrawal of an employment offer or immediate discharge

    I understand that this application is not a contract of employment.

    I authorized and request my former employers, references, and educational institutions which have information about me, to give J Heart Healthcare any and all information and opinions about me in their possession and which may lawfully be disclosed. I hereby waive written notice of such release of information and opinions, and release such former employers, references, and educational institutions from any liability or claim relating to such release of information and opinions. I also authorized and request federal, state, and local governmental agencies to release to J Heart Healthcare any information requested, concerning any criminal convictions on my record. A photocopy of this signed authorization and waiver shall be valid as an original.

    Signature of applicant:

    Date:

    Release Of Information

    I hereby authorized all prior employers, schools, credit bureaus, Social security Administration. Law enforcement agencies and investigative agencies to give J Heart Healthcare all information concerning my previous employment and any pertinent information they may have personal or otherwise, concerning my qualifications for the position applied for. I release to J Heart Healthcare and all its employees form all liability for any damage that may result from furnishing information to J Heart Healthcare. I also release to J Heart Healthcare and all its employees from all liability for any damage that may result from reliance on the information furnished. I understand that if a consumer investigative report is requested, I have the right under the Fair Credit Reporting Act to request in writing, within a reasonable time, a complete and accurate disclosure of the nature and scope of the investigation. This written request should be addressed to the location where this application is filed.

    Full Name (Please Print):

    Social Security Number:

    Signature of applicant:

    Date:

    J Heart Healthcare

    Conflict Of Interest

    I acknowledge that I have read the company policy statement concerning conflict of interest and I hereby declare that neither I, nor any other business to which I may be associated, nor, to the best of my knowledge, any member of my immediate family has any conflict between our personal affairs or interests and the proper performance of my responsibilities for the company that would constitute a violation of that company policy. If I terminate my employment with J Heart Healthcare, I will not work for any patient I have worked for with J Heart Healthcare for a period of two years or pay a fine of $2,500.00. All assignments are considered Per Diem, there are no full or part time positions with J Heart Healthcare due to the demands of the patients, and change in patient’s condition and needs. Furthermore, I declare that during my employment, I shall continue to maintain my affairs in accordance with the requirements of said policy.

    Signature of applicant:

    Date:

    J Heart Healthcare is a licensed Developmental Disabilities Administration (DDA) provider agency in Maryland.

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