Give a complete record of all employment and reasons for periods of unemployment during past ten years. Start with most recent employment. Give U.S. experience only.
I understand that this is an application for employment and that no employment contract is being offered at this
time. Any material misrepresentation or deliberate omission of a fact in my application may be justification for
refusal or, or if employed, immediate termination of employment.
It is my understanding that the hospital will make a through investigation of my entire work and personal
history and may verify all data given in my application for employment, related paper, or interviews. I authorize
such investigation and the giving and receiving of any information requested by the hospital and I release from
liability any person giving or receiving any such information. I understand that falsification of data so given or
other derogatory information discovered as a result of this investigation may prevent my being hired, or if hired,
may subject me to disciplinary action or dismissal.
I understand that I must be able to perform the position tasks for which I’ve applied. I must complete a preplacement
physical examination by a qualified medical physician and flexibility screening by the hospital
Physical Therapist at no cost to me. Also, if employed, I must complete future physical examinations as
required by the hospital at my own cost. I authorize any physician or hospital to release any information
verbally or in writing, which may be necessary to determine my abilities to satisfactorily perform the job duties
I am applying for are and are employed therein.
I further agree that if employed, I will serve the hospital to the best of my abilities and abide by the established
policies. I understand that if I do not, I may be subject to disciplinary action and /or dismissal.