Apply Now – Tennessee State Veterans Home

APPLICATION FOR EMPLOYMENT

The Tennessee State Veterans’ Homes Board complies with all applicable federal and state laws prohibiting discrimination in hiring or employment practices on the basis of citizenship, race, color, religion, gender, age, national and ethnic origin, disability, or veteran status. No question or item on this application for employment is intended to secure information to be used for such discrimination. Information obtained through this application will be used solely to determine qualifications and suitability for employment. This application will be valid for a period of 90 days from date of completion.

Location at Which You Wish to Apply - Check Only One:*

CLK - Clarksville
HUM - Humboldt
KNO - Knoxville
MUR - Murfreesboro
CLE - Cleveland

Date of Application:*

Date Available for Employment:*

Name:*

First Middle Last

Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email Address:*

Phone

(day)

Phone

(evening)

Other names under which you have worked

Type of Employment desired:*

Full-Time
Part-Time
PRN
Temporary

Shift Preferred:*

Days
Evenings/Nights
Weekends Only
Specific hours/days only

Specific hours/days only:

Position:*

RN
LPN
CNA
Housekeeping
Laundry
Dietary
Other

Other Position:

How were you referred to TSVHB?*

Newspaper
Friend/Relative
TSVH Employee
TSVH Website
Facility Reputation
Other

Other:

Employment Eligibility Information

Are you legally authorized to work in the United States?*

Yes
No

Type of Authorization:*

Document Number:*

Expiration Date:*

Have you ever pleaded guilty or been convicted of a crime?

Yes
No

If “Yes,” briefly explain the specific offense(s), where the offense(s) occurred, and the penalty or sentence imposed:

NOTE: A “Yes” answer does not necessarily disqualify you from employment with TSVHB

Offense(s):*

Date:*

Location:*

Sentence or Penalty:*

Have you ever been employed by TSVHB at any of its locations?*

Yes
No

If “Yes” where did you work and under what name?

Start Date:*

End Date:*

Have you ever had a license (other than a driver’s license) investigated, suspended, revoked, sanctioned, placed on probation or subjected to any conditions?*

Yes
No

If “Yes,” please explain:*

Have you ever been terminated or asked to resign from any job?*

Yes
No

If “Yes,” please explain:

Do you have any commitments to another employer? If yes, please state with whom and explain how they may affect your employment with TSVHB.*

Yes
No

If “Yes,” please explain:

Have you ever served in the military?*

Yes
No

Branch:*

Have you ever been placed on an abuse registry?*

Yes
No

If “Yes,” please explain:

Regardless of any accommodations you might need, can you perform the essential functions of the job for which you applied?*

Yes
No

Education and Training

High School

School/City and State:*

Major:*

# Years:*

Degree/Diploma:*

College

School/City and State:*

Major:*

# Years:*

Degree/Diploma:*

Other

School/City and State:*

Major:*

# Years:*

Degree/Diploma:*

Professional Credentials

License / Certification held:

Type of License*

State*

Number*

Expiration Date*

Employment History

Please list all previous employment and provide all requested information. Begin with your most recent job and do not omit any employment information. You must explain all gaps in employment.

I authorize TSVHB or its representatives to investigate and verify any and all of the information provided and to give any additional information in response to reference questions intended to determine my suitability for employment. I hereby release all investigators, previous employers, schools, organizations, individuals and TSVHB from any liability for providing or receiving such information.

Signature*

Date

May we contact for reference?*

Yes
No

Name of Employer

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Job Title:

Supervisor:

Phone

Employed from (Start Date):

Employed until (End Date)

Employment Type

Full-time
Part-time
PRN
Temp.

Job Responsibilities:

Reason for Leaving:

Ending Salary:

Signature*

Date

Employment History

I authorize TSVHB or its representatives to investigate and verify any and all of the information provided and to give any additional information in response to reference questions intended to determine my suitability for employment. I hereby release all investigators, previous employers, schools, organizations, individuals and TSVHB from any liability for providing or receiving such information.

Signature

Date

May we contact for reference?*

Yes
No

Name of Employer

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Job Title:

Supervisor:

Phone

Employed from (Start Date):

Employed until (End Date)

Employment Type

Full-time
Part-time
PRN
Temp.

Job Responsibilities:

Reason for Leaving:

Ending Salary:

Signature

Date

Applicant Statement

I hereby affirm that the information I have provided in this application (and the accompanying resume, if any) is true and complete to the best of my knowledge. I understand that any falsified, misrepresented, incomplete or omitted information may disqualify me from consideration for employment or result in my dismissal from employment.

I understand that nothing contained in this employment application, or in granting an interview, is intended to create an express or implied employment contract between the Tennessee State Veterans’ Homes Board and myself. No promises regarding employment or duration of employment have been made to me.

I understand that any offer of employment will be conditional on successful completion of a number of pre-employment requirements, including verification of credentials and experience, criminal background and abuse registry checks, drug/alcohol screen, attendance at a general orientation program, and any other requirements specified by the Tennessee State Veterans’ Homes Board. I understand that if any employment relationship is established, either the Tennessee State Veterans’ Homes Board or I have the right to terminate the relationship at any time and for any reason. I understand that if hired I am required to abide by all policies and procedures of the Tennessee State Veterans’ Homes Board.

By submitting this application, I authorize the Tennessee State Veterans’ Homes Board or its representatives to investigate and verify any and all of the information contained in this employment application, including a criminal background check, abuse registry, licenses, and inquiry into the OIG sanction list. I also authorize all previous employers, schools, organizations and individuals listed herein to verify any and all information I have provided and to give any additional information in response to reference questions intended to determine my suitability for employment. I hereby release all investigators, previous employers, schools, organizations, individuals and the Tennessee State Veterans’ Homes Board from any liability for providing or receiving such information.

Signature

Date

TSVH Mission Statement

The Tennessee State Veterans’ Home’s mission is to provide the best possible services to those who have served the United States of America and to their family members who have also made sacrifices for our country. Our goal is to provide them with the best health care by delivering quality and compassionate care in an environment which is pleasant and enjoyable: to provide a safe, warm and happy home for our veterans in a place where they can feel secure, and where they are treated with the dignity and respect they deserve.

We proudly serve those who served.

References

List three Professional References (no relatives) we may contact other than your previous employers.

Reference #1

Name:

Relationship:

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone:

Fax:

Email

Reference #2

Name:

Relationship:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone:

Fax:

Email:

Reference #3

Name:

Relationship:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone

Fax:

Email

I authorize TSVHB or its representatives to investigate and verify any and all of the information provided and to give any additional information in response to reference questions intended to determine my suitability for employment. I hereby release all investigators, previous employers, schools, organizations, individuals and TSVHB from any liability for providing or receiving such information.

Applicant Signature

Date

Candidate Disclosure, Authorization & Consent for the Procurement of Consumer Reports

Section I: Disclosure

Tennessee State Veteran’s Homes Board (the “Company”) may request background information about you from a consumer reporting agency in connection with your employment application and for employment purposes. The report ordered is defined by the Fair Credit Reporting Act (FCRA) as a Consumer Report, and all inquiries are limited to information that affects job performance and the workplace. It is conducted in accordance with applicable federal and state laws including the FCRA. The screening will be conducted by an outside agency — GoodHire, LLC. – P.O. Box 391146 Omaha, NE 68139 | 1-‐888-‐906-‐7351 | mailto:support@goodhire.com. As a result, GoodHire may obtain a Consumer Report on you as an applicant or during employment.

A consumer report is a compilation of information that might affect your employability. The scope of the report may include information concerning your driving record, civil and criminal court records, credit, worker’s compensation record, education, credentials, identity, past addresses, social security number, previous employment and personal references.

Should an employer rely upon a consumer report for an adverse action, the FCRA mandates you be provided with a copy of the consumer report and a summary of your rights. An adverse action is defined as “a denial of employment or any other decision for employment purposes that adversely affects any current or prospective employee.”

Section II: Authorization and Release

I have carefully read and understand this Candidate Disclosure, Authorization & Consent for the Procurement of Consumer Reports form and the attached summary of rights under the Fair Credit Reporting Act. By my signature below, I consent to the release of consumer reports and investigative consumer reports prepared by a consumer reporting agency, such as GoodHire, LLC., to the Company and its designated representatives and agents. I understand that if the Company hires me, my consent will apply, and the Company may obtain reports, throughout my employment. I also understand that information contained in my job application or otherwise disclosed by me before or during my employment, if any, may be used for the purpose of obtaining consumer reports and/or investigative consumer reports. By my signature below, I authorize law enforcement agencies, learning institutions (including public and private schools and universities), information service bureaus, credit bureaus, record/data repositories, courts (federal, state and local), motor vehicle records agencies, my past or present employers, the military, and other individuals and sources to furnish any and all information on me that is requested by the consumer reporting agency. By my signature below, I certify the information I provided on this form is true and correct and will be valid for any reports that may be requested by or on behalf of the Company.

Consent*

I authorize GoodHire and its agents to contact my current employer if necessary to verify my current employment status.

Applicant Name:

Applicant Email:

Applicant Signature:

Date:

If you are resident of, or performing jobs located in, California, Minnesota, Oklahoma, Massachusetts or New York, you can receive a free copy of any Consumer Report, Investigative Consumer Report or Credit Report by contacting GoodHire at 1-888-906-7351 or support@goodhire.com at 1-888-906-7351 or support@goodhire.com.

Section III: A Summary of Rights Under The FCRA

The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under the FCRA. For more information, including information about additional rights, go to http://www.ftc.gov/credit or write to: Consumer Response Center, Room 130---A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, DC 20580.

• You must be told if information in your file has been used against you. Anyone who uses a credit report or another type of consumer report to deny your application for credit, insurance, or employment – or to take another adverse action against you – must tell you, and must give you the name, address and phone number of the agency that provided the information.

• You have the right to know what is in your file. You may request and obtain all the information about you in the files of a Consumer Reporting Agency (your “file disclosure”). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

A person has taken adverse action against you because of information in your credit report;
You are the victim of identity theft and place a fraud alert in your file;
Your file contains inaccurate information as a result of fraud;
You are on public assistance;
You are unemployed but expect to apply for employment within 60 days.

In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See http://www.ftc.gov/credit for additional information.

• You have the right to ask for a credit score. Credit scores are numerical summaries of your credit worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

• You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate and report it to the Consumer Reporting Agency, the agency must investigate unless your dispute is frivolous. See http://www.ftc.gov/credit for an explanation of dispute procedures.

• Consumer reporting agencies must correct or delete inaccurate, incomplete or unverifiable information. Inaccurate, incomplete or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

• Consumer reporting agencies may not report outdated negative information. In most cases, a Consumer Reporting Agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

• Access to your file is limited. A Consumer Reporting Agency may provide information about you only to people with a valid need --- usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

• You must give your consent for reports to be provided to employers. A Consumer Reporting Agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to http://www.ftc.gov/credit.

• You may limit “prescreened” offers of credit and insurance you get based on information in your credit report. Unsolicited “prescreened” offers for credit and insurance must include a toll---free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt---out with the nationwide credit bureaus at 1-888-567-8688.

• You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

• Identity theft victims and active duty military personnel have additional rights. For more information, visit http://www.ftc.gov/credit.

States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General. Federal enforcers are:

TYPE OF BUSINESS:	PLEASE CONTACT:
Consumer reporting agencies, creditors and others not listed below	Federal Trade Commission: Consumer Response Center – FCRA Washington, DC 20580 1-877-382-4357
National banks, federal branches/agencies of foreign banks (word “National” or initials “N.A.” appear in or after bank’s name)	Office of the Comptroller of the Currency Compliance Management, Mail Stop 6-‐6 Washington, DC 20219 800-613-6743
Federal Reserve System member banks (except national banks, and federal branches/agencies of foreign banks)	Federal Reserve Board Division of Consumer & Community Affairs Washington, DC 20551 202-452-3693
Savings associations and federally chartered savings banks (word “Federal” or initials “F.S.B.” appear in federal institution’s name)	Office of Thrift Supervision Consumer Complaints Washington, DC 20552 800-842-6929
Federal credit unions (words “Federal Credit Union” appear in institution’s name)	National Credit Union Administration 1775 Duke Street Alexandria, VA 22314 703-519-4600
State-‐chartered banks that are not members of the Federal Reserve System	Federal Deposit Insurance Corporation Consumer Response Center 2345 Grand Avenue, Suite 100 Kansas City, MO 64108-‐2638 1-877-275-3342
Air, surface, or rail common carriers regulated by former Civil Aeronautics Board or Interstate Commerce Commission	Department of Transportation, Office of Financial Management Washington, DC 20590 202-366-1306
Activities subject to the Packers and Stockyards Act, 1921	Department of Agriculture Office of Deputy Administrator- GIPSA Washington, DC 20250 202-720-7051