STATEMENT OF APPLICANT
(PLEASE READ CAREFULLY) In applying for employment I
want County Memorial Hospital to be fully
informed of my previous record, and I hereby authorize County Memorial Hospital to investigate my
background and to obtain any and all information which may
concern me. I hereby release all persons, schools,
corporations, military and government agencies, credit
bureaus and law enforcement agencies from any liability in
furnishing such information.
I understand that the County Memorial Hospital
policy requires me to submit a sample of my urine and blood
for chemical analysis to determine the presence or absence
of drugs and/or alcohol. I consent feely and voluntarily
to provide such urine and/or blood specimens prior to start
of my employment and I understand that employment is
contingent upon passage of this chemical analysis. I
further consent to any future request for urine and/or blood
specimens pursuant to the County memorial
Hospital Alcohol and Drug Policy. I hereby release and
hold harmless County Memorial Hospital and its
employees and agents from any liability whatsoever arising
from any and all requests to furnish specimens or the
testing process. I also authorize any laboratory
testing my urine and/or blood pursuant to the
County Memorial Hospital Alcohol and Drug Policy to release
the results to County Memorial Hospital and I hereby
release any such laboratory, its employees and agents and
hold them harmless from any liability whatsoever arising
from the release of such information to County
Memorial Hospital.
I fully understand that any
misrepresentation of facts on this application shall be
sufficient cause for dismissal in the event I am hired, or
shall be sufficient cause for the preclusion of further
consideration of my application prior to being hired.
I further understand that any offer of employment shall be
subject to reference check. I understand and agree
that, should I be offered employment, my commencement of
work may be conditioned on the results of a medical
examination, the cost of which, if administered., will be
borne by County Memorial Hospital. I
further agree to abide by the policies, procedures and
practices of County Memorial Hospital. I
further understand that this employment relationship is at
will and may be terminated by either party at any time, with
or without cause.
RELEASE: 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 licensure status and my
licensure history.
Checks this box to indicate you have read and accept the
terms this STATEMENT OF
APPLICANT.
Email
Address
If called for an interview, you will be
asked to sign a copy of this application.
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