Employment

Please provide three professional references.

I, the undersigned hereby give my permission for West Ridge Care Center of Cedar Rapids, Iowa to conduct a criminal history and dependent adult abuse check with the division of Criminal Investigation. I also give permission for West Ridge Care Center to conduct an OIG exclusion list check that is maintained by the Attorney General's office of the United States. I further understand that my future employment with West Ridge is, in part dependent upon the results of this record check.

Pursuant to federal law, health care providers are prohibited from employing individuals who have been placed on the OIG Exclusion List maintained by the Attorney General's Office of the United States. Employers have a continued obligation to periodically check weather employees have been placed on these lists and must maintain current information regarding the identification of their employees.

I certify that the above information provided is true and complete to the best of my knowledge. I understand that the Facility might investigate all statements made in this document and that any false or misleading information I have provided can result in a decision to immediately discharge or lead to civil or criminal penalties as appropriate.

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.