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Personal Information

Education and Training

Professional License/Certification

Work Experience (List present or most recent employment first)




Reference

Personal Reference

Immediate Past Employer or Education Reference

Applicant's Statement and Authorization

I understand that if employed by Pontiac Care and Rehabilitation Center, LLC. I will be and employee at will, which means that I can voluntarily end my employment or be terminated at any time for any reason or no reason at all. No statement whether written or oral, by any Company representative other than a written statement signed by the Owner may vary the foregoing. I give Pontiac Care and Rehab Center, LLC permission to contact all or any of my previous employers and references and authorize then to provide all information requested of them by Pontiac Care and Rehab Center, LLC. After a tentative offer of employment has been made, I agree to take a job-related medical examination at my personal expense and authorize the examining physician to disclose the findings to Pontiac Care and Rehab Center. I understand that any offer of employment is conditional upon receipt of satisfactory references and satisfactory completion of such job-related medical examination.

I have provided truthful and complete responses to all inquiries in the application and understand that the discovery of any falsification, omission or misleading information given in my application or interview constitutes a ground for immediate dismissal. If employed, I will abide by Pontiac Care and Rehabilitation Center's rules and regulations, which I understand are subject to change by Pontiac Care and Rehabilitation Center, LLC.

Employment Verification and Reference Request

has applied to Pontiac for the position of and has listed you as a former employer. Please complete the form below and return it promptly in the enclosed envelop of fax to (315) 343-1821. Thank you

Authorization/Release. I hereby authorize Pontiac Care and Rehabilitation Center, LLC to contact any/all of my previous employers for full information, I authorize my previous employers to release such information and release the company or person named above from all liability for completing this form.



has applied to Pontiac for the position of and has listed you as a former employer. Please complete the form below and return it promptly in the enclosed envelop of fax to (315) 343-1821. Thank you

Authorization/Release. I hereby authorize Pontiac Care and Rehabilitation Center, LLC to contact any/all of my previous employers for full information, I authorize my previous employers to release such information and release the company or person named above from all liability for completing this form.



I undertand that the following information is required ass a condition of employment with Pontiac Care and Rehabilitation Center. I further acknowledge that I understand that I will be subjected to a background check prior to active employment. (Applicant should be prepared to submit the following documentation on or before the scheduled date of orientation)

  • 1. Acceptable documents that establish both identity and employment authorization
  • 2. Physical within the last six (6) months
  • 3. Proof of PPD
  • 4. MMR Vaccination or Titer (If applicable born after 01/01/1957)
  • 5. Influenza Immunization informed consent
  • 6. Hepatitis Vaccination (If Available)

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