Online Application for Employment Omaha Tribe of Nebraska Carl T. Cutis Health Education Center Attention: Human Resources Dept. P.O. Box 250 Macy, NE 68039 Date Date Format: MM slash DD slash YYYY Position Applied For*Name First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code PhoneWhat is the highest level of education completed High School Diploma/GED Associates Degree Bachelor's Degree Master's Degree Doctorate Degree Certification/Licensure Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?* Yes No Date available to work if selected? Date Format: MM slash DD slash YYYY Have you ever been convicted of a felony or misdemeanor?* Yes No ie. Theft, DUI, ect (other than minor traffic violations)If yes please explain.EMPLOYMENT HISTORY:Please give accurate, complete information about any full-time or part-time employment starting with your current or most recent job first.EmployerSupervisor First Last PositionFrom Date Format: MM slash DD slash YYYY DateTo Date Format: MM slash DD slash YYYY DateMay We Contact? Yes No Starting PayEnding PayResponsibilitiesReason for LeavingResumeConsent* Applicant's StatementIt is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the Omaha Tribe's service if I have been employed. I understand that no representative of the Omaha Tribe has the authority to make any assurance to the contrary. I am aware an additional background check may be conducted prior to hire and/or during employment due to Federal/State rules and regulations, which may prevent or remove an applicant from obtaining employment. I give the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the Omaha Tribe and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. I am aware pre-employment drug screening, annual drug screening and screening conducted due to reasonable suspicion. The Omaha Tribe is an Equal Opportunity Employer. The Omaha Tribe does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state, or federal law. This application is currently on file for 6 months. At the conclusion of this time, if I have not heard from the Omaha Tribe and still wish to be considered for employment, it will be necessary to fill out a new application. We consider applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-related medical condition or any other legally protected status. Omaha Tribe of Nebraska Release of informationI understand that, my name will be checked against Nebraska Department of Health and Human Services Adult/Child Protective Services Central Registers. A check of these registers is necessary to ensure that I meet provider standards. The purpose of this check will determine if my name is being maintained on either register as a result of previous abuse/neglect allegations which have been investigated and have not been determined to be unfounded. To the best of my knowledge, I do not have a conviction or prior history of adult or child abuse/neglect or maltreatment Neither have I been convicted of a crime involving moral turpitude. I hereby authorize the Nebraska Department of Health and Human Services to release information contained on the Adult or Child Protective Services Central Register including the information that a record has been found to:
