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    Employee Questionnaire for Voluntary Self-Identification

    The above information is true and correct. I understand that, in the event that I become employed by Allegria Senior Living, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery. I hereby give my consent to any former employer to provide employment-related information about me to Allegria Village including but not limited to: my past employment. I authorize all persons and organizations to release any information concerning my background and hereby release all persons and organizations from liability for any damage whatsoever for issuing this information. I acknowledge that a telephone facsimile(FAX) or photographic copy shall be valid as the original and will hold Allegria Senior Living and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information. I further authorize Allegria Senior Living to obtain credit and consumer check information. I understand that this employment application does not create an employment contract between me and Allegria Senior Living. I also understand and agree that, if hired, my employment may be terminated by me or Allegria Senior Living at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing. If employed, I will be required to provide original documents that verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of 1986. The document(s) provided will be used for completion of Form-I-9.

    Please read ALL instructions carefully before completing this form.

    Voluntary Notice: Allegria Senior Living is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite our employees to voluntarily self-identify their gender and race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

    Anti-Discrimination Notice: It is an unlawful employment practice for an employer to fail or refuse to hire or discharge any individual, or otherwise to discriminate against any individual with respect to that individual’s terms and conditions of employment, because of such individual’s race, color, religion, sex, or national origin. Henry Ford Village is an equal opportunity employer, we hire without consideration to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, veteran status, or disability.