Applying for Name: Address: If employed and you are under the age of 18, can you furnish a work permit? Yes No Have you filled out an application with us before today? Yes No Have you ever been employed here? Yes No Will you be able to provide evidence of eligibility to work in the U.S.? Yes No Are you available to work: Full Time Part Time What shift(s)? MWF TThS Either/Both Are you on lay-off or any status that would subject you to recall? Yes No Do you have reliable transportation to work? EDUCATION REFERENCES Give the names and phone numbers of 3 business references, who are not listed below and who are not related to you, but who are familiar with your work performance. EMPLOYMENT EXPERIENCE
Start with your present or most recent job. Include military service assignment and volunteer activities. If you need additional space, attach another sheet of paper.
We consider applications for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status.
As employers/governmental contractors, we comply with government regulations.
I understand that any employment by this facility will be on a 90 day probationary basis. If employed by Dialysis Care Center (DCC)- Parent Company of Home Dialysis Services (HDS), I agree to abide by its rules and regulations. The above information is complete and true to the best of my knowledge. I understand that the discovery, misrepresentation or omission of facts herein will be cause for immediate dismissal. I authorize this facility to contact any or all of my references for full information. I am aware that offers of employment are contingent on completing and passing a drug screen, criminal background check and other pre-employment screenings deemed necessary. I am aware that I may be requested to take any said tests/ screenings at the request of this company, and agree that the medical personnel or party chosen may disclose the finding to this facility or an authorized agent of this company. I warrant and represent that I am not an agent for any other party and that I have a fiduciary duty to the employer. I further specifically warrant and represent that I am not now and have not been in the past an employee or agent of any newspaper, television or any other media service, and have a duty not to invade the privacy of any patient of DCC or HDS. I also authorize Dialysis Care Center and or Home Dialysis Services to provide employment information to inquiries over the telephone. Voluntary Survey
Government agencies at times require periodic reports on sex, ethnicity and other protected status of applicants. This data is for analysis and possible affirmative action only.
SUBMISSION OF THIS INFORMATION IS STRICTLY VOLUNTARY. Please check one of the following: Male Female Please check one of the following: Race/Ethnic Group: African American/Black Hispanic Native American Caucasian/White Asian/Pacific Islander IMPORTANT NOTICE TO ALL DCC / KCC APPLICANTS:
In accordance with the State of Illinois Criminal Identification Act (93-0211/20 ILCS 2630/12) effective January 1, 2004:
“An expunged or sealed record may not be considered by any private or public entity in employment matters, certifications, licensure, revocation of certification or licensure or registration.”
Please note that when applying for a position with Dialysis Care Center - Parent Comapny of Home Dialysis Services, you are NOT obligated to disclose any sealed or expunged records of convictions or arrests, nor will you be asked if you have had records expunged or sealed.
Please refer any questions to the Human Resources Department at Dialysis Care Center.
I understand that I am not obligated to disclose any expunged and/or sealed records of convictions or arrests.