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Employment Application


Education and Training




Position you are applying for

Please Read and Complete Carefully

ALL Applicants must complete the required information in Question below: A conviction will not necessarily bar you from employment consideration

List other qualifications and skills (e.g. languages, typing, office machines, etc.) Please list job related organizations, clubs, professional societies, or other associations to which you belong (you may omit those of which may indicate your ace, color, religion, sexual orientation, national origin, gender, age, veteran status, marital status or disability.

Employment History




Professional / Work Related References




ALL LICENSED CLINICAL HEALTHCARE PROFESSIONALS MUST COMPLETE THE FOLLOWING SECTION







Please Read Each Statement Carefully Before Signing


I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my immediate dismissal if discovered at a later date.

I understand that the employer may request an investigate consumer report agency, as well as a check of my criminal background. I understand that should this application or a criminal record check reveal a conviction of a crime, further processing of this or my employment, if hired may be terminated.

If offered employment, I will, as a condition of employment, be required to submit proof of my identity and legal right to work in the U.S. I UNDERSTAND that I will be required to possess a current and valid driver’s license if my job requires me to drive in the course of my work.

I AUTHORIZE the investigation of any or all statements contained in this application and also authorize any person, school, recent employer (except as previously noted), past employers and organizations from any legal liability in making such statements. I hereby fully wave any rights or claims I have or may have against all current and/or former employers, and agents, employees, and representatives and damages that may directly or indirectly result from the use, disclosure or in-case of any information by any person or party, whether such information is favorable or unfavorable to me. I further any claim against ACCOUNTABLE SOURCE INC. , as a of any information that is obtained in this investigation.

This application is submitted with the understanding that upon acceptance of a formal employment offer, I will be required to successfully pass ACCOUNTABLE SOURCE, INC.’s pre-placement testing, which will include a drug screen. I consent to the of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am

I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME WIT OR WITHOUT CAUSE AND WITHOUT NOTICE, AT THE OPTION OF THE COMPANY OR MYSELF.

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