Secure Application for Employment
It is the policy of this facility to provide equal opportunity to persons regardless
of race, religion age, gender, disability or any other classification in accordance with federal,
state and local statutes, regulations and ordinances.
This Application can be active as long as legally required.
Current Open Position for Which You Are Applying: Primary Care Physician
Arrests or charges that have been expunged need not be disclosed.
College #2 (if applicable)
Licensing and Certifications
List any professional licenses, registration or certification you possess (Include Driver's License, if applicable)
If the position you are applying for requires you to drive, please answer these three questions:
Please list all work history from most recent to oldest
Current or Most Recent
Professional References (Other than Relatives)
Give references who have good knowledge of your work.
Please review and acknowledge that you understand the following.
In submitting this application for employment:
* I certify that the information in this application is true and complete for all
practical purposes. It may be verified by the facility. Should
a position be offered and later it is found that the information is significantly
untrue, incomplete, or misrepresented, I understand and agree that the facility
is relieved of all commitments, financial or otherwise pertinent
to employment, and that I am subject to immediate discharge without recourse.
I authorize this employer to thoroughly investigate my
references, work record, education and other matters related to my suitability for
employment, (e.g., motor vehicle operator records, criminal records, school records,
licensure records, etc. ) and further authorize the references I have listed to
disclose to the company and all letters, reports, and other information related
to my work records, without giving me prior notice of such disclosure. In addition,
I release this employer, my former employers and all other
persons, corporations, partnerships and associations from any and all claims, demands
or liabilities arising out of or in any way related to such investigation or disclosure.
I UNDERSTAND AND AGREE THAT ANY POLICIES WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT.
Compliance with this facility's Substance Abuse Policy is a condition of employment.
This hospital requires that every newly hired employee be free of drug
abuse. I understand and acknowledge that I may be required to submit to a physical
examination, including drug testing. I hereby authorize the release
of the results of such an examination to this employer
for their use in evaluating my suitability for employment. Further, I release the
examining facility and this employer from any and all liability,
and from any damage that may result from the release of such information. Each offer
of employment is contingent upon successfully completing a urinalysis test/screen
for drugs in accordance with hospital policy.
* I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT
WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY WILL HAVE THE RIGHT
TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND
WITH OR WITHOUT NOTICE, I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY
A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND
IS SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY.
I hereby authorize any prior employers to provide such information concerning my
employment with them as may be requested, and also authorize the Registrar/Placement
Office of all educational institutions attended to release an official copy of my
transcript and, if available, faculty appraisals. I also authorize any appropriate
licensing board to release full information concerning my license status and my
By submitting this application,
I agree that all of the preceding questions
are answered truthfully and to the best
of my abilities.
List maiden names and/or other names used.
Disclosure Regarding Background Investigation & Authorization
DISCLOSURE AND ACKNOWLEDGEMENT (IMPORTANT — PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGEMENT)
This employer may obtain information about you from a consumer
reporting agency for employment purposes. Thus, you may be the subject of a “consumer
report” which may include information
about your character, general reputation, personal characteristics, criminal information,
motor vehicle records (“driving records”), sex offender
status, education verification, professional license, Social Security
Verification, employment history, and personal history
a conditional offer of employment has been made)
. You have the right, upon written
request made within a reasonable time after receipt of this notice, to request whether
a consumer report has been run about you, and the nature and scope of any investigative
consumer report, and request a copy of your report.
ACKNOWLEDGEMENT AND AUTHORIZATION
I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY
OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read
and understand both of those documents. In consideration of my application, I authorize
this employer by and through to verify all data given by
me on my application, related papers or oral interviews. I hereby authorize the
obtaining of “consumer reports” and/or “investigative consumer reports” at any time
after receipt of this authorization and, if I am hired, throughout my employment.
To this end, I hereby authorize, without reservation, any employers, agencies, personal
references, law enforcement agency, administrator, state or federal agency, institution,
school or university (public or private), information service bureau or insurance
company and other persons with whom I am acquainted to answer all questions and
release all information including but not limited to my employment record, character,
reputation, ability, education, military service, credit history and other applicable
reports and/or furnish any and all background information requested by ESS, or another
outside organization acting on behalf of this employer.
Furthermore, I release all agencies, bureaus, employers, information service organizations
and individuals or companies named above from all liabilities or damages that might
result from information provided in good faith. I state that the information provided
by me on my application is accurate and I agree that if any information is found
to be false at any time, my application may be discarded or my employment terminated.
I understand that the information requested below regarding sex and date-of-birth
are for the sole purpose of gathering the above information accurately and will
not be used to discriminate against me in violation of the law. I agree that a facsimile
(“fax”), electronic or photographic copy of the Authorization shall be as valid
as the original.