EMPLOYMENT HISTORY
Please list all current and previous employers below for the last 5-10 years. Please indicate rather we can contact the supervisor as a reference.
JOB PERFORMANCE ABILITY
Do you now have or anticipate having any activities, commitments or responsibilities that may prevent you from meeting your work requirements?
YesNo
Given your knowledge, skills, education and experience, are you able to perform all the essential functions of the position for which you are applying, with or without reasonable accommodation, as set forth in the job description? NoYes
Would you be able to represent AKT Healthcare ’ interests, meaning adhering to all company policies and procedures for the commission of duties both onsite and offsite?YesNo
DISCLAIMER AND SIGNATURE
APPLICANT CERTIFICATION - PLEASE READ CAREFULLY
I understand that this position is not a contract, offer or promise of employment. I acknowledge that employment with this company is on an employment basis. This means that my employment with this company can be terminated at any time, with or without cause or advance notice and acceptance of employment is not a contract of employment for any specified time. Similarly, I am free to terminate my employment with the company at any time for any reason. This at-will provision may be modified or waived only in a written agreement signed by the company’s Program Director/Designee and me.
I further understand that I am responsible for being familiar with the AKT Healthcare Systems, Inc. policies, rules and regulations, and I understand that the company has complete discretion to modify its policies, rules, regulations and practices at any time, to the extent permitted by the federal, state and local law, except that it will not modify its policy of employment at will. By my continued employment with AKT, I consent to any such changes.
I certify that the above information, including resume submitted, is complete and accurate to the best of my knowledge and I agree to complete any requisite authorization forms. I authorize AKT Healthcare Systems, Inc. and its subsidiaries to verify all information prior to the receipt of an employment offer. I understand that any falsification, misrepresentation or omission of information on this form or relating to my application of employment may result in my denial of employment, or if employed, my immediate dismissal. Furthermore, I release all parties from any liability arising out of this provision and the use of such information.
AKT Healthcare Systems, Inc. is an equal opportunity employer.
