Applicant Information

We are an equal opportunity employer and prohibits discrimination or harassment on the basis of race, color, religion, national origin, ancestry, sex, age, martial status, familial status, sexual orientation, disability, or status as a covered veteran. Reasonable accommodations for the needs of otherwise qualified applicants with disabilities will be made upon request.

Education

Military Service

Licensure

References

Please list three professional references.

Previous Employment

Disclaimer and Signature

I understand and agree that the acceptance of this application by the company does not constitute a promise that I will be hired. I further understand that the company does not guarantee employment for any specific length of time and, therefore, agree that if I am hired my employment may be terminated by either the company or me at any time without cause or notice.

If I am employed by the company, I agree to abide by the rules and regulations of the company. I fully understand that all records pertaining to my employment are to remain the property of the company, and that hours of work and other working conditions are subject to change at the organization’s discretion.

I certify that I fully understand all requests for information contained in this application, and I certify that the information supplied by me, on this form and elsewhere in conjunction with obtaining employment, is complete and correct to the best of my knowledge and hereby grant the company permission to verify such answers and investigate all references including a criminal history check with local, state and federal agencies as well as a background check for fraud and abuse with the Cumulative Sanction Report and National Practitioner Databank. I understand that any false or misleading statements, omission, or misrepresentation on this application will be considered sufficient cause for rejection of this application or for dismissal, if such information or omission is discovered subsequent to my employment.

I authorize the employers, schools, or persons named above to give any information regarding my previous employment, character, general reputation, and other personal characteristics, together with any information regarding me, whether or not it is in their records. I understand that under the Federal Fair Credit Reporting Act, I have the right to make written request within a reasonable period of time for the complete and accurate disclosure by the company of the nature and scope of any credit investigation requested. I hereby release the company, employers, schools, or persons from all liability for any damage resulting from issuing the information. I further certify that I have not entered into any agreement with any previous employer or other organization that would prevent or restrict my employment with the company at this time or in the future.

In consideration of my employment, I agree to submit to pre-placement screening and periodic physical examinations and evaluations, including, but not limited to, diagnostic testing, as the company, from time to time, deems reasonably necessary to determine my fitness to perform the work for which I was hired. I understand that, as a condition of employment, I may be required to submit to testing for the illegal use of drugs. If the testing reveals evidence of the illegal use of drugs, any offer(s) of employment extended to me will be unconditionally revoked regardless of whether I have or have not begun employment.

I further attest that I am not disqualified from employment which excludes individuals with convictions for prohibitive offenses. If the criminal background check reveals evidence of any prohibited offense, any offer(s) of employment extended to me will be unconditionally revoked regardless of whether I have or have not begun employment.

I understand and agree that when my employment is terminated, I must return all property in my custody belonging to my employer. To be employed, I understand I must be lawfully authorized to work in the United States and that I must show documented proof of authorization. The company is an Equal Opportunity Employer.