Applicants are considered for all positions without regard to race, color, religion, gender, national origin, age, marital or veteran status, or the presence of non-job-related medical condition or handicap.
Employment Experience
Start with your present or last job. Include military service assignments and volunteer activities. Exclude organization names which indicate race, color, religion, gender or national origin.
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Military Service
Indicate languages you speak, read and/or write.
Language #1:
Language #2:
Language #3:
Applicant’s Statement
I certify that answers given herein are true and complete to the best of my knowledge.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that this application is not and is not intended to be a contract of employment.
In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of NCE Homecare.
I hereby release NCE Homecare from any liability for information received during the application process, including, but not limited to, information about criminal misconduct, theft and other violations of law.
I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law.
Reference Form
Emergency Contact Information
Notify in Case of Emergency #1:
Notify in Case of Emergency #2:
CRIMINAL BACKGROUND HISTORY
In completing this criminal background history, pursuant to Connecticut General Statutes Section 31-51i, note that:
(A)(1) You are not required to disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased pursuant to section 46b-146, 54-76o or 54-142a, (2) criminal records subject to erasure pursuant to section 46b-146, 54-76o or 54-142a are records pertaining to a finding of delinquency or that a child was a member of a family with service needs, an adjudication as a youthful offender, a criminal charge that has been dismissed or nolled, a criminal charge for which the person has been found not guilty or a conviction for which the person received an absolute pardon, and (3) any person whose criminal records have been erased pursuant to section 46b-146, 54-76o or 54-142a shall be deemed to have never been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so swear under oath;
(B) You will not be denied employment solely on the basis that you had a prior arrest, criminal charge or conviction, the records of which have been erased pursuant to section 46b-146, 54-76o or 54-142a or that you had a prior conviction for which you received a provisional pardon or certificate of rehabilitation pursuant to section 54-130a, or a certificate of rehabilitation pursuant to section 54-108f.
(1) Have you ever been arrested?*
(2) If so, please provide the date, and circumstances, of the arrest*
(3) Have you ever been charged with a crime?*
(4) If so, please provide the date, and the crime, with which you were charged.*
(5) Have you ever been convicted of a crime?*
(6) If so, please provide the date, and the crime, for which you were convicted.*
(7) Have you ever been convicted of a crime involving violence or dishonesty in a state court or federal court in any state?*
(8) If so, please provide the date, and the crime, for which you were convicted.*
(9) Have you ever been subject to any decision imposing disciplinary action by a licensing agency in any state, the District of Columbia, a United States possession or territory or a foreign jurisdiction?*
(10) If so, please provide the date, and nature, of such disciplinary action.*
Applicant’s Statement – Criminal Background History
I certify that answers given herein are true and complete to the best of my knowledge.
As part of my employment application, I hereby authorize NCE Homecare to conduct a criminal background check; further, if I am hired by NCE Homecare, I hereby authorize NCE Homecare to conduct future criminal background checks, at any time.
I certify that the statements made by me on this application are true and complete to the best of my knowledge and are made in good faith. I understand that if I knowingly make any misstatements of fact, I am subject to disqualification, dismissal, or other action pursuant to employment agency policy and procedure, and subject to criminal penalties as prescribed by law.
NOTICE
Information obtained in your criminal background check will be used to reach decision on your employment application.
If we retain a company to prepare an “investigative report” on your background, that is, a report based on personal interviews concerning your personal character, general reputation, personal characteristics, and lifestyle, you will have the right to a description of the nature and scope of the investigation.
Upon performing your criminal background check, we will certify to the company performing such check that (1) you were notified of the criminal background check, and provided your permission to obtain a criminal background report; (2) we have complied with all Fair Credit Reporting Act requirements; and (3) don’t discriminate against any applicant or employee, or otherwise misuse the information in violation of federal or state equal opportunity laws or regulations.
Pre-Employment Drug Screening Acknowledgement Form
It is the policy of NCE Homecare to conduct urinalysis drug testing, when legally permissible, at any time pre-employment or during employment. Positive test results or failure to show for testing may result in disciplinary action up to and including termination of employment.
As part of your employment application:
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You are hereby advised of NCE Homecare’s intention to conduct a urinalysis drug test as part of your employment application, and you hereby consent to such drug testing;
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The urinalysis drug test will be conducted in accordance with the requirements of subdivisions (1) and (2) of subsection (a) of section 31-51u of the Connecticut General Statutes;
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You will be provided with a copy of any positive urinalysis drug test result.
