Professional Reference/Criminal Background Check Authorization - HHA/CNA
Phone: (248) 395-3777, Fax: (248) 395-3370, www.hchs.com28000 Woodward Ave., Ste 100., Royal Oak, MI 48067

Professional Reference #1

AUTHORIZATION (Please provide current legal name and legal name at time of employment):
I authorize you to furnish HealthCall of Detroit, Inc. with information concerning my previous employment record, job performance and character, and I release you from liability for providing this information.
Signature of Applicant: *
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Reference #1 Information

Professional Reference #2

AUTHORIZATION (Please provide current legal name and legal name at time of employment):
I authorize you to furnish HealthCall of Detroit, Inc. with information concerning my previous employment record, job performance and character, and I release you from liability for providing this information.
Signature of Applicant: *
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Reference #2 Information

Professional Reference #3

AUTHORIZATION (Please provide current legal name and legal name at time of employment):
I authorize you to furnish HealthCall of Detroit, Inc. with information concerning my previous employment record, job performance and character, and I release you from liability for providing this information.
Signature of Applicant: *
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Reference #3 Information

Criminal Background Check Authorization

I certify that the facts, answers, and information given by me in this application, my resume, and in any other materials I have submitted are true, accurate, and complete. I understand that, if employed, my employment may be terminated immediately if HealthCall discovers that I have withheld or omitted any information, or provided false, inaccurate, or misleading information in this application, my resume, or any other materials submitted, or in any other document or form executed by me at any time during my employment.

I authorize HealthCall to verify the information provided and to investigate my background as deemed necessary. I authorize former employers, personal references, or other agencies, institutions, or persons (collectively referred to as "person") to provide HealthCall any information they have regarding me without receiving written notice from me. I hereby release and agree to hold harmless from liability and covenant not to sue any person providing information pursuant to this authorization. I hereby waive written notice by my present and/or former employers whenever a disciplinary report, letter, reprimand or other action regarding me is divulged to HealthCall by present or former employers. I understand that employment arising out of this application is contingent upon the results of the investigation. I also understand that HealthCall may condition an offer of employment upon my passing a physical examination, including a drug test, prior to employment.
I agree to immediately notify Human Resources if I should be arrested for a felony or convicted of a crime, including a plea of no contest, during my tenure at HealthCall.

In consideration of my employment, I agree and understand that my employment and compensation can be terminated with or without notice and with or without cause either at my option or at the option of HealthCall, it being mutually understood and agreed that my relationship with HealthCall is one of employment at-will, and no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Any agreement altering the at-will nature of the employment relationship must be in writing and signed by me and an authorized company representative. I also understand and agree that any fringe benefits I receive as a result of my employment may be modified by HealthCall and do not vest by reason of my employment or continued employment, and that fringe benefits are subject to change by HealthCall with or without notice to me.

I agree not to commence any action or lawsuit including, but not limited to, claims arising under state or federal civil rights statutes related to my application for employment or employment against HealthCall or its employees, more than one hundred eighty (180) days after the occurrence of the facts giving rise to the claim, or more than one hundred eighty (180) days after the date of my termination of employment, whichever is earlier, and to waive any longer statute of limitations to the contrary. In the event that the statute of limitations applicable to any such claim is less than one hundred eighty (180) days, I agree that the shorter statute of limitations shall apply.

I understand that Michigan law requires employers to make accommodations to disabled applicants and employees where the accommodation does not impose an undue hardship on the employer. I further understand that disabled employees and applicants must request an accommodation of their disability by notifying HealthCall in writing of the need for accommodation within one hundred eighty two (182) days of the date the individual knows or should know that an accommodation is needed. Failure to properly notify HealthCall will preclude any claim that HealthCall to accommodate the disability under state law.

Please read the above carefully before signing the employment application. Your signature, whether handwritten or electronic, indicates that you have read, understand, and agree to the above statements and conditions of employment. Your signature also indicates that you understand and agree that, if hired, you will be subject to all rules, regulations, policies, and practices of HealthCall in force at the time of your employment or that may later be adopted.
I certify that I am the person named on this application, and I agree to all terms and conditions contained in this application as well as associated forms and authorizations.

Signature: (Please use your mouse to sign your name.  You need to hold down left click while signing your name.) *
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