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I understand that signing this box constitutes a legal signature confirming all information provided on this application is true and accurate. 


The information I have provided in this Application for Employment is true, correct and complete.  False,  incomplete or misrepresented information of any kind, will be sufficient cause for my application to be rejected or,  if discovered after I am employed, cause for immediate termination of my employment.

I authorize the employer to contact and obtain information about me from previous employers, educational institutions, and “references” I provided, and any other party necessary to verify the accuracy of information I disclosed in this application, a related employment resume or a personal interview.  To assist in the processing of my application, I waive all rights and claims I may otherwise have against the employer or its representatives, for seeking, and using information to evaluate my employment request and all other persons, corporations or organizations who provide information for this purpose. 


This application is not an employment agreement.  If I accept an offer of employment I understand I may resign at any time, and the employer may terminate my employment at any time, with or without cause and without prior notice, unless required by law.

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Willow Health Care, Inc. is committed to providing equal employment opportunities to qualified employees and applicants for employment, based upon each person’s performance, qualifications, and abilities.  WHCI does not discriminate in employment opportunities or practices on the basis of race color, sex, religion age, national origin, veteran status, pregnancy status, ancestry, marital status, sexual orientation, gender identity, genetic information, disability, citizenship status, and/or any other protected status.  Equal opportunity extends to all aspects of the employment relationship, including hiring, transfers, promotions, training, terminations, working conditions, compensation, benefits, and any other terms and conditions of employment.

     Missouri state law requires healthcare providers to undergo a criminal background check within two days of hiring.  The law applies to any position where the employee would have contact with patients or residents in a
convalescent home, nursing home, boarding home, providers of in-home services under contract with Missouri Department of Health and Senior Services, employers of temporary nurses, and nursing assistants place in healthcare of medical treatment facilities.
    Applicants must provide written authorization before submitting to a background check.  In addition, applicants must disclose if they have ever been convicted of a felony or misdemeanor, have any suspended sentences or executions or sentence, have any periods of probation or parole, or are listed on the employee disqualification list (EDL).
   Employers cannot employ individuals who have been convicted of, pled guilty or no contest to, or have been guilty or statutorily specified class A or B felonies in any state (sex offenses, offenses against a person), or
are on the employee disqualification list (EDL).  The undersigned has applied to provide services to this provider and will have contact with patients or residents.

I consent to this provider to conduct a criminal background check and open/closed records review, as well as requesting the Missouri governmental entities to inform the provider if my name appears of any of their
disqualification or background check lists.  I understand this information will not be further disclosed other than for the purpose of application and employment and that the provider may refuse to hire or engage me based onthe results of its inquiries. 

I further state that the following are true statements and if subsequently become untrue, I will immediately notify my employer.

• I am not listed on any employee disqualification list (EDL).
• I am registered with the Family Care Safety Registry (FCSR) or I will register within 15 days of employment with this provider.  **Anyone hired on or after January 1, 2001, as an elder-care worker is required to make application for registration in the Family Care Safety Registry within 15 days of the beginning of employment.  Such persons who fails to submit a completed registration form to the Missouri Department of Health without good cause, as determined by the department, is guilty of a class B misdemeanor.
• I have not been convicted of or plead guilty to (including any suspended imposition or execution of sentence or any period of probation or parole) any misdemeanor or felony except for what I listed on my employment application.

Applicant further represents and warrants to WHCI that Applicant is not excluded from participation in any federal health programs, as defined under 42 U.S.C. 1320a-7b (f) or any form of state Medicaid program, and to Applicants knowledge, there are not pending or threatened governmental investigations that may lead to such exclusion.  Applicant further represents and warrants to WHCI that Applicant is not debarred from participation in any federal health care programs, or any form of state Medicaid programs, and to Applicants knowledge, there are no pending or threatened governmental investigations that may lead to such debarment.  If an applicant is employed by WHCI, Applicant agrees to notify WHCI of the commencement of any such exclusion, debarment, or investigation within 7 days of Applicant’s first learning of it.  Company shall have the right to immediately terminate Applicant’s employment upon learning of such exclusion, debarment or investigation.  Applicant agrees to notify WHCI of the status of any such investigation.  

Current Signature

Willow Health Care, Inc.
Employee Consent to Drug and/or Alcohol Testing

                                                                consent to submit to urine, saliva, breathe, blood, and/or hair testing for illegal drugs or alcohol as provided in Willow Health Care, Inc. drug/alcohol testing policies.  (Reference: Part 1, Section F, “Drug-Free Workplace” and Part 1, Section X, “Drug/Alcohol Testing”)  I have been given a copy of these policies and I have reviewed their contents.  I agree to abide by the policies and I understand and agree that complying with the policies is a condition my continued employment with Willow Health Care, Inc.  If I do not consent to submit to urine, saliva, breathe, blood, and/or hair testing within a reasonable timeframe, I understand that I will be subject to termination of employment.


I also understand that if I test positive to any of the testing methods, it will result in automatic termination of my employment with Willow Health Care, Inc.  Furthermore, I authorize the release of the test results to my
employer, and/or, on post-accident tests, the company’s workers’ compensation insurance carrier and understand the refusal to release these results is grounds for termination.  I understand that if I test positive
for drugs or alcohol following an on-the-job accident, I may be ineligible for workers’ compensation benefits or have benefits reduced by 15% as allowed by Missouri law.

I understand that Willow Health Care, Inc. is obligated to report positive drug/alcohol testing and termination of employment of licensed employees to the Missouri State Board of Nursing, as outlined in 4CSR 20-4.

I voluntarily consent to testing for the detection of the following illegal drugs and alcohol:  Alcohol; Amphetamines, Methamphetamine; Barbiturate; Benzodiazepines; Cannabinoid (Marijuana); Cocaine; Methadone, Methylenedioxymethamphetamines, Opiates/Morphine; Oxycodone, Buprenorphine,
and Phencyclidine.  I also understand I may produce a legal prescription for any of the prior named drugs and this will release me from termination of employment.

I agree that a photocopy of this consent form has the same effect as the original and may be used in place of the original consent form.

I understand that signing this box constitutes a legal signature 

Current Signature
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All employees are subject to pre-employment or post-employment drug test as well as periodic, random selection for drug testing and post accident drug testing.  A confirmed positive test result (prior to employment) will exclude the applicant from employment with the company for a minimum period
of six months, after which time the applicant can reapply for consideration.  Any employee’s or applicant’s refusal to submit to a test or a test result that indicates that the sample provided has been diluted, adulterated, is not the product of the employee, or has been tampered with will result in
the individual not being considered for employment &/or disciplinary action up to termination.  Random drug testing of employees will occur on a periodic basis reasonably spread throughout the year.  Refusal or failure to
submit to a timely drug/alcohol test is sufficient cause for termination of employment.  WHCI will incur the cost of the drug- screening.  

          For Cause
Any employee who behavior is consistent with substance abuse can be required by their immediate supervisor to submit to a drug/alcohol screen.  Collected specimens will be analyzed by a certified laboratory.  One positive reading will automatically terminate the employment of the employee, unless the employee has a legal prescription for the drug they tested positive for.  Behavior indicating substance abuse may include:
•    Observed impairment of job performance
•    Abnormal conduct or erratic behavior
•    A number of minor workplace accidents
•    Evidence of drug tampering in the employee’s workplace
•    Arrest or conviction on an alcohol or drug related offense

          Post Accident
An incident occurring while on WHCI business that results in injury (requiring medical treatment) to an employee or others and/or damage to WHCI property will be subject to drug/alcohol testing.

        DOT Requirements
Employees that fall under drug-testing rules by the Department of Transportation will be subject to random drug/alcohol testing.  Testing is also required following an accident and when there is reasonable suspicion
of drug/alcohol use.  






If possible, please attach a copy of your Social Security card and Driver's License.

You may also attach additional documents to support your application such as a resume, certificates, additional experience, or other pertinent information.

Work experience will be used to calculate starting wages so please make sure to include all work history.

Current Signature