I am hereby advised by the Company that it is necessary to conditionally employ, independently contract and/ or grant clinical privileges to me employee prior to receiving all of the results of the state and national criminal history background information required by Public Act XX of 2006. Accordingly, I make the following representations while this information is obtained and analyzed: (1)                I swear under penalty of law that I have not been convicted of a felony or misdemeanor within the applicable time period that makes me ineligible, by law to work for this organization. I have reviewed the attached list of felonies and misdemeanors prior to making this representation. (2) I am not the subject of an order or disposition under section 16b of Chapter IX of the code of criminal procedure, 1927 PA 175, MCL 769.16(b.) relating to finding of not guilty by reason of insanity. (3) I have not been the subject of a substantiated finding of neglect, abuse, or misappropriation of property by a state or federal agency pursuit to an investigation arising in a skilled nursing facility and conducted in accordance with 42 USC 1395i-3 or 1396r. (4) I agree that if the information in the criminal history investigation conducted by this organization does not confirm my statements, my employment, contract or clinical privileges will be terminated unless and until I can prove that the information is incorrect. I further agree that if this results in a period of unemployment, suspension, or leave of absence, it will be without compensation and without fringe benefits. (5) I understand the conditions set forth in Public Act XX of 2006 that result in my termination and agree that these conditions are in fact good cause for termination. (6) I am aware that the provision of false information regarding my identity or criminal history is a crime punishable by fines and/ or imprisonment. 

Pursuant to Public Act XX of 2006, I agree, that as a condition of employment or contract, I will immediately report to the Company any arraignment or conviction of one or more of the criminal offenses listed below: (1) Felony – Any felony or attempt or conspiracy to commit ANYfelony. (2) Misdemeanor– Any misdemeanor listed below. [a.] A misdemeanor involving abuse or neglect. [b.] A misdemeanor involving cruelty or torture unless otherwise provided under subdivision (e). [c.] A misdemeanor that involving criminal sexual conduct. [d.] A misdemeanor that involves vulnerable adult abuse under chapter XXA of the Michigan Penal Code, 1931 PA 328, MCL 750.145m to 750.145r. [e.] A misdemeanor involving the use of a firearm or dangerous weapon with the intent to injure, the use of a firearm or dangerous weapon that results in a personal injury, or a misdemeanor involving the use of force or violence or the threat or the use of force or violence. [f.] A misdemeanor involving cruelty if committed by an individual who is less than 16 years of age. [g.] A misdemeanor involving home invasion. (h.) A misdemeanor involving embezzlement. (i.) A misdemeanor involving negligent homicide. [j.] A misdemeanor involving larceny unless otherwise provided under subdivision(g). [k.] A misdemeanor involving retail fraud in the second degree unless otherwise  provided under subdivision(g). [l.] Any other misdemeanor involving assault, fraud, theft, or the possession or delivery of a controlled substance unless otherwise provided under subdivision (d), (f), or (g). [m.] A misdemeanor for assault if there was no use of a firearm or dangerous weapon and no intent to commit murder or inflict great bodily injury. [n.] A misdemeanor for retail fraud in the third degree unless otherwise provided under subdivision (g). [o.] A misdemeanor under part 74 of the public health code, 1978 PA 368, MCL 333.7401 to 333.7461 relating to controlled substances, if the individual, at the time of conviction, is under the age of 18. [p.] A misdemeanor for larceny or retail fraud in the second or third degree it the individual, at the   time of conviction, is under the age of 16. I also agree to immediately report whether I become the subject of an order or disposition finding of not guilty by reason of insanity. I further agree to immediately report being the subject of a substantiated finding of neglect, abuse, or misappropriation of property by a state or federal agency pursuant to an investigation conducted in relation to a skilled nursing facility. 

I consent that the Company may conduct a background check that includes review and obtainment of State Police records, fingerprints, FBI background check, and Driving Records. The consent has been granted pursuant to my receipt of a good faith offer acceptable to the Michigan State Police.  

This good faith offer is also conditioned upon the organization’s ability to successfully establish eligibility for employment, independent contractor or privileges on a timely basis. The eligibility determination is made at the sole discretion of the Company and will be based not only on company policy on good moral character and references, but also the information obtained through the mandatory background check and fingerprinting requirements imposed by PUBLIC ACT XX OF 2006.  This conditional offer is also conditioned upon the applicant’s full cooperation with the production of acceptable personal identification, obtainment of signed releases, consent forms, criminal history records, fingerprints and the obtainment of any other information required by policy or law. Failure to comply fully with all of the requirements within 10 business days will result in the automatic withdrawal of this offer.