Nursing Scholarships Consent Form

First Name

Middle

Last Name

Home Phone

Work Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Are you currently employed at the University of Kentucky?

Yes

No

Have you ever been previously employed by the University of Kentucky?

Yes

No

At the Lexington Campus?

Yes

No

At UK HealthCare?

Yes

No

At the Bluegrass Community and Technical College?

Yes

No

At KCTCS?

Yes

No

Dates of Employment

If you answered yes to any of the employment questions above, please provide full name under which you were employed, date(s) of employment, and department. (Please limit text to no more than three lines.)

Names of Relatives Employed at the University

Name of any relative(s) currently employed by the University (include relationship and department). (Please limit text to no more than three lines.)

Licenses

Please list all licenses and certifications (driver’s, CDL, teaching, nursing, CPA, vocational, etc.) that you possess.

Please list license information in this format: Professional license/certification / Registration number / State or licensing authority / Expiration date

Licenses
	Licenses	Item weight

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If you are NOT a United States citizen, do you have the necessary immigration permission and documentation to work in the U.S.?

Yes

No

Not Applicable (N/A)

Permanently

Yes

No

Not Applicable (N/A)

Temporarily

Yes

No

Not Applicable (N/A)

VISA Type

What are your job interests (for example, NICU, OB, ED, pediatrics, ICU, etc.) Please do not list more than three.

What are your job interests (for example, NICU, OB, ED, pediatrics, ICU, etc.) Please do not list more than three.
	What are your job interests (for example, NICU, OB, ED, pediatrics, ICU, etc.) Please do not list more than three.	Item weight

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Professional References (Include: Name, Title, Company, Phone)

List below the names, titles, and phone numbers of three professional references that would be able to address your work habits, skills and abilities.

Professional References (Include: Name, Title, Company, Phone)
	Professional References (Include: Name, Title, Company, Phone)	Item weight

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Current / Last Supervisor (Include: Name, Title, Phone, Company)

May we contact this individual for a reference?

Yes

No

Felonies

Have you ever pleaded guilty to, or been convicted by a judge or jury of, a felony in this state or in any other state, or do you have any pending felony charge(s)? You must report any felony, even if probation, parole, an Alford Plea or pretrial diversion occurred?

Yes

No

If you answered "Yes" to the above question, please provide the details of each conviction or pending felony charge below, including DATE (month/year), LOCATION (city, county, state), and NATURE of ALL felony convictions or pending felony charges. Failure to list ALL felony convictions or pending felony charges may be considered a falsification of this application and result in: the withdrawal of an offer of employment, restriction on applying for any other positions at the University, and/or termination from any current employment with the University of Kentucky. It is not acceptable to substitute "will discuss in interview" for this information (please use a separate sheet if more than four):

Please list your: Date of conviction(s) or pending felony charge(s) Month and Year - Location of conviction (City/County/State)

Please list your: Date of conviction(s) or pending felony charge(s) Month and Year - Location of conviction (City/County/State)
	Please list your: Date of conviction(s) or pending felony charge(s) Month and Year - Location of conviction (City/County/State)	Item weight

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Pre-employment records verifications are conducted. If you are unsure of this information, visit your local police department and request a copy of your records. A conviction will not necessarily prevent you from being employed at the University of Kentucky.

I certify that all answers to the questions in my resume/application and this Consent Form are true, and I further understand that any false statement and/or omissions in this resume/application will be sufficient grounds for rejection of the resume/application, or termination of employment.
I authorize the University to make any and all necessary and appropriate investigations to verify the information contained herein, including criminal records, educational credentials, and work experience. References obtained are done so in confidence.
I understand that, if hired in a Regular status (non-temporary) with the University, I will be required to enroll and participate in the University’s retirement plan as of my attainment of age thirty (30). Failure to do so shall result in termination of employment.
I understand if I am offered a position, I may be required to successfully pass a pre-employment drug screen. I further understand that refusal or failure to appear for a scheduled pre-employment drug screen, refusal to disclose test results, or a positive drug screen indicating the presence of illegal drug(s) or inappropriate use of legal drugs, will result in the withdrawal of any job offer. Further, a positive drug screen or failure to submit for drug screening shall result in my being ineligible for hire for any position at the University of Kentucky for a minimum period of one (1) year.
I understand if I am offered a position, I may be required to undergo a pre-employment national background check as mandated by University of Kentucky Human Resources.
I understand that, if hired, I will be required to sign this document in front of a University representative if I initially submitted it electronically or by fax.

In signing this document, I hereby certify that I have read the above information, that I understand the above information, and that I agree to abide by the above information.

Signature

Date

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Nursing Scholarships Consent Form