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    Personal Information

    Are you eligible to work in the United States? YesNo

    If you are under the age of 18, do you have an employment/age certificate? YesNoN/A

    Position / Availability

    Days Available MondayTuesdayWednesdayThursdayFridaySaturdaySunday

    Shift Availability DaysEveningsNights

    When are you available to start work? (YYYY-MM-DD)


    Please supply the Names and Addresses, along with degrees or diplomas and graduation dates of schools you have attended.

    Work History


    Have you ever been convicted of?

    Crimes of violence against persons including but not limited to assault and battery, rape, or armed robbery? YesNo

    Crimes against property including but not limited to burglary and vandalism? YesNo

    Crimes of dishonesty including but not limited to forgery, passing bad checks, embezzlement? YesNo

    Crimes of or connected to use/or traffic in drugs and alcohol, including but not limited to drunk driving, possession and use of banned substances? YesNo

    Have you ever been convicted of a crime (excluding misdemeanors and traffic offenses) other than those listed? YesNo

    Courtyard Healthcare Center conducts pre-employment drug screening. Do you object to participating in the screen? YesNo

    I certify that the above information is true and complete. I understand that any false statement I have made herein or my failure to disclose requested information may disqualify me for consideration of employment, or if employed, may result in my termination. I further authorize Courtyard Healthcare Center or its agents to perform an investigation of local state and federal records relating to any criminal convictions I may have. In addition, Courtyard Healthcare Center has my permission to obtain all necessary information from the references I have listed, or any other sources, concerning my prior employment, personal history, or criminal history and I release all parties from any possible damages resulting from disclosing such information with or without prior written notice of me.
    I understand and acknowledge that I may be required to undergo a post-offer pre-employment physical exam and a post-offer pre-employment drug screening analysis for substance abuse. I understand that these may, to the extent permitted by law, result in the revocation of any offer of employment.
    I certify that this application does not constitute and employment contract of any kind. I further acknowledge that, if I am offered a position with Courtyard Healthcare Center, my employment may be terminated at any time, with or without cause, except as otherwise provided by law.


    I acknowledge receipt of the separate document entitled DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" by Courtyard Healthcare ("Employer") at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Verified First, 1550 South Tech Lane, Suite 200, Meridian, Idaho 83642; Tel.# 1-888-670-9564; www.VerifiedFirst.com and/or Employer. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original.

    New York applicants only: Upon request, you will be informed whether or not a consumer report was requested by the Employer, and if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer report requested by the Employer by contacting the consumer reporting agency identified above directly. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.

    New York City applicants only: You acknowledge and authorize the Employer to provide any notices required by federal, state or local law to you at the address(es) and/or email address(es) you provided to the Employer.

    Washington State applicants only: You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

    Minnesota and Oklahoma applicants only: Please check this box if you would like to receive a copy of a consumer report if one is obtained by the Employer.


    Disclosure Regarding Background Investigation

    Courtyard Healthcare Center, the "Company," may obtain information about you from a third party consumer reporting agency for employment purposes. Thus, you may be the subject of a
    "consumer report" which may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records ("driving records"), verification of your education or employment history (including income), or other background checks.
    You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you and to request a copy of your report. These searches will be conducted by Verified First, Phone: 888-670-9564, Fax: 208-266-2310, Mailing Address:, 1550 S Tech Lane Suite 200 Meridian, ID 83642. To the extent permitted by law, the Company may obtain consumer reports from any outside organization throughout the course of
    your employment.

    I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and certify that I have read and understand this document.


    Para informacion en espanol, visit www.consumerfinance.gov/1earnmore o escribe a la Consumer
    Financial Protection Bureau, 1700 G Street N. W., Washington, DC 20552.
    The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of information in the files of consumer reporting agencies. There are many types of consumer reporting agencies, including credit bureaus and specialty agencies (such as agencies that sell information about check writing histories, medical records, and rental history records). Here is a summary of your major rights under FCRA. For more information, including information about additional rights, go to www.consumerfinance.gov/learnmore or write to: Consumer Financial Protection Bureau, 1700 G Street N.W., Washington, DC 20552.

    You must be told if information in your file has been used against you. Anyone who uses a credit rep on or another type of consumer rep on to deny your application for credit, insurance, or employment -or to take another adverse action against you - must tell you, and must give you the name, address, and phone number of the agency that provided the information.

    You have the right to know what is in your file. You may request and obtain all the information about you in the files of a consumer reporting agency (your "file disclosure"). You will be required to provide proper identification, which may include your Social Security number. In many cases, the disclosure will be free. You are entitled to a free file disclosure if:

    a person has taken adverse action against you because of information in your credit rep on; you are the victim of identity theft and place a fraud alert in your file;

    your file contains inaccurate information as a result of fraud;

    you are on public assistance;

    you are unemployed but expect to apply for employment within 60 days.

    In addition, all consumers are entitled to one free disclosure every 12 months upon request from each nationwide credit bureau and from nationwide specialty consumer reporting agencies. See www.consumerfinance.gov/learnmore for additional information.

    You have the right to ask for a credit score. Credit scores are numerical summaries of your credit-worthiness based on information from credit bureaus. You may request a credit score from consumer reporting agencies that create scores or distribute scores used in residential real property loans, but you will have to pay for it. In some mortgage transactions, you will receive credit score information for free from the mortgage lender.

    You have the right to dispute incomplete or inaccurate information. If you identify information in your file that is incomplete or inaccurate, and report it to the consumer reporting agency, the agency must investigate unless your dispute is frivolous. See www.consumerfinance.gov/learnmore for an explanation of dispute procedures.

    Consumer reporting agencies must correct or delete inaccurate, incomplete, or unverifiable information. Inaccurate, incomplete, or unverifiable information must be removed or corrected, usually within 30 days. However, a consumer reporting agency may continue to report information it has verified as accurate.

    Consumer reporting agencies may not report outdated negative information. In most cases, a consumer reporting agency may not report negative information that is more than seven years old, or bankruptcies that are more than 10 years old.

    Access to your file is limited. A consumer reporting agency may provide information about you only to people with a valid need - usually to consider an application with a creditor, insurer, employer, landlord, or other business. The FCRA specifies those with a valid need for access.

    You must give your consent for reports to be provided to employers. A consumer reporting agency may not give out information about you to your employer, or a potential employer, without your written consent given to the employer. Written consent generally is not required in the trucking industry. For more information, go to www.consumerfinance.gov/learnmore.

    You many limit "pre-screened" offers of credit and insurance you get based on information in your credit report. Unsolicited "pre-screened" offers for credit and insurance must include a toll-free phone number you can call if you choose to remove your name and address from the lists these offers are based on. You may opt out with the nationwide credit bureaus at 1-888-5-OPTOUT (1-888-567-8688).

    The following FCRA right applies with respect to nationwide consumer reporting agencies:


    You have a right to place a "security freeze" on your credit report, which will prohibit a consumer reporting agency from releasing information in your credit report without your express authorization. The security freeze is designed to prevent credit, loans, and services from being approved in your name without your consent. However, you should be aware that using a security freeze to take control over who gets access to the personal and financial information in your credit report may delay, interfere with, or prohibit the timely approval of any subsequent request or application you make regarding a new loan, credit, mortgage, or any other account involving the extension of credit.

    As an alternative to a security freeze, you have the right to place an initial or extended fraud alert on your credit file at no cost. An initial fraud alert is a 1-year alert that is placed on a consumer's credit file. Upon seeing a fraud alert display on a consumer's credit file, a business is required to take steps to verify the consumer's identity before extending new credit. If you are a victim of identity theft, you are entitled to an extended fraud alert, which is a fraud alert lasting 7 years.
    A security freeze does not apply to a person or entity, or its affiliates, or collection agencies acting on behalf of the person or entity, with which you have an existing account that requests information in your credit report for the purposes of reviewing or collecting the account. Reviewing the account includes activities related to account maintenance, monitoring, credit line increases, and account upgrades and enhancements.

    You may seek damages from violators. If a consumer reporting agency, or, in some cases, a user of consumer reports or a furnisher of information to a consumer reporting agency violates the FCRA, you may be able to sue in state or federal court.

    Identity theft victims and active duty military personnel have additional rights. For more information, visit www.consumerfinance.gov/learnmore.


    States may enforce the FCRA, and many states have their own consumer reporting laws. In some cases, you may have more rights under state law. For more information, contact your state or local consumer protection agency or your state Attorney General.
    For information about your federal rights, contact:

    Type of Business Contact
    1.a. Banks, savings associations, and credit unions with total assets of over $10 billion and their affiliates a. Consumer Financial Protection Bureau 1700 G Street, NW., Washington, DC 20552
    b. Such affiliates that are not banks, savings associations, or credit unions also should list, in addition to the CFPB: b. Federal Trade Commission Consumer Response Center 600 Pennsylvania Avenue, N.W., Washington, DC 20580 (877)382-4357
    2. To the extent not included in item 1 above:a. National banks, federal savings associations, and federal branches and federal agencies of foreign banks a. Office of the Comptroller of the Currency Customer Assistance Group 1301 McKinney Street, Suite 3450, Houston, TX 77010-9050
    b. State member banks, branches and agencies of foreign banks (other than federal branches, federal agencies, and Insured State Branches of Foreign Banks), commercial lending companies owned or controlled by foreign banks, and organizations operating under section 25 or 25A of the Federal Reserve Act. b. Federal Reserve Consumer Help Center P.O. Box.1200, Minneapolis, MN 55480
    c. Nonmember Insured Banks, Insured State Branches of Foreign Banks, and insured state savings associations c. FDIC Consumer Response Center 1100 Walnut Street, Box #11, Kansas City, MO 64106
    d. Federal Credit Unions d. National Credit Union Administration Office of Consumer Financial Protection (OCFP) Division of Consumer Compliance Policy and Outreach 1775 Duke Street, Alexandria, VA 223 14
    3. Air carriers Asst. General Counsel for Aviation Enforcement & Proceedings Aviation Consumer Protection Division Department of Transportation 1200 New Jersey Avenue, S.E., Washington, DC 20590
    4. Creditors Subject to the Surface Transportation Board Office of Proceedings, Surface Transportation Board Department of Transportation 395 E Street, S.W. Washington, DC 20423
    5. Creditors Subject to the Packers and Stockyards Act, 1921 Nearest Packers and Stockyards Administration area supervisor
    6. Small Business Investment Companies Associate Deputy Administrator for Capital Access United States Small Business Administration 409 Third Street, S.W., Suite 8200, Washington, DC 20416
    7. Brokers and Dealers Securities and Exchange Commission 100 F Street, N.E., Washington, DC 20549
    8. Federal Land Banks, Federal Land Bank Associations, Federal Intermediate Credit Banks, and Production Credit Associations Farm Credit Administration 1501 Farm Credit Drive, McLean, VA 22102-5090
    9. Retailers, Finance Companies, and All Other Creditors Not Listed Above Federal Trade Commission Consumer Response Center 600 Pennsylvania Avenue, N.W., Washington, DC 20580 (877) 382-4357

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    All of you, Every one of you are so amazing!!  You are angels in disguise.  I do not know how you do your job with such grace and heartfelt love and concern.  Thank you so very much for the kind care you administered to my Dad!  You are outstanding in service and we were so blessed that our Dad was able to be a resident of Courtyard!  Your kind care of Alvin made a huge difference in "our world."  Thank you, too, for your generous and kind accommodation during our Dad's passing.   God Bless each and every one of you!

    — Polly Byines