819 NE 122nd Ave.
Portland, OR 97230
503-252-0085
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Please complete all pages of this application. Read all sections carefully and sign the document at the end of the application.

PERSONAL INFORMATION :

EDUCATION

LICENSURE AND CERTIFICATION

EMPLOYMENT HISTORY

Name and Address of your last (most recent first) employer

BUSINESS & PERSONAL REFERENCES (List business references first)

Note :

Sapphire Health Services, LLC is committed to equal employment ln all of its employment practices. Decisions involving every aspect of the employment relationship are made without regard to an employee's race, color, creed, religion, gender, sexual orientation, age, national origin, marital status, veteran status, worker compensation, disability, or any other status or characteristic protected under applicable state or federal law, unless it is a bona fide occupational requirement necessary to the normal operation of the business.

NOTIFICATION & AGREEMENT

Please read carefully; answer each question and sign at the bottom.

Your application will become valid only when you sign and date it. If you have any questions regarding these statements, please ask them before signing: Your application will be given every consideration but its receipt does not imply you will be employed.

Your signature authorizes Sapphire Health Services, LLC to seek and obtain a report from the State of Oregon or Washington, Motor Vehicle Records Department. Your signature also authorizes Sapphire Health Services, LLC to obtain state or federal background check information as required to work with vulnerable persons. It is understood that should background Information be obtained that is untoward, an offer of employment will not be given, or may be rescinded.

AGREEMENT
  1. I understand the following: Sapphire Health Services, LLC may elect to engage an investigative consumer reporting agency to discover and report on my credit and personal history. If such a decision is made, the company will provide me with further required Information: and that my signature on this application gives the employer authority to engage such and agency.
  2. I certify that all answers and statements I have made on this application, and any other accompanying required • documents are true and complete without omissions. I understand that any falsifications, misrepresentations or omission of fact on this application or any other accompanying or required documents will be cause for denial of employment or immediate termination of employment regardless of when or how discovered.
  3. I understand that my employment may be subject to the satisfactory results of any examination required by this facility, including a mandatory urine test to detect drug usage and hereby submit to said testing. I agree to conform to all rules and regulations of the company as they presently exist or are later modified. l recognize that my employment is at will and may be terminated at the discretion of the company or at option, without notice.
  4. I understand that nothing contained in this employment application or in the grant if of an interview is intended to create a contract between this facility and myself for employment for any specified period of time, or to assure me of any future position, benefits, or terms and conditions of employment.
  5. I acknowledge that 1 have read, understand, and agree with the above. In addition, I hereby authorize any of the persons • of the organizations named in the application, or any other accompanying or required documents to give you complete information and records regarding my employment, education, character and qualifications. This application is only valid for the position being applied for.