An ineligible person is any individual or entity who is currently excluded, suspended, debarred or otherwise ineligible to participate in Federal Health Care programs; or has been convicted of a criminal offense related to the provision of
health care items or services and has not been reinstated in the Federal Health Care Programs after a period of exclusion, suspension, debarment, or ineligibility.

Please Review and Sign Where Indicated.

In making application for employment:

• I certified that the information in this application is true and complete for all practical purposes. It may be verified by the facility or any affiliate. 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 or its affiliates are relieved of all commitments, financial or otherwise pertinent to employment, and that I am subject to immediate discharge without recourse.
• I understand that an investigative report may be made by a consumer reporting agency to include information as to my character, general reputation, persona characteristics, and mode of living, whichever may be applicable. If such an
  investigative report is made, I understand that I will receive  notice that such report has been requested, and that I will
  have the right to make a written request for a complete and accurate disclosure of additional information concerning the nature and scope of the investigation.
• I UNDERSTAND AND AGREE THAT ANY EMPLOYEE HANDBOOK WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT, BUT WILL BE MERELY A GRATUITOUS STATEMENT OF FACILITY POLICIES.
• I understand that the facility reserves the right to require its employees to submit to blood tests or urinalyses for alcohol or drug screens, or to allow inspection of bags (including purses or briefcases) or parcels brought into or taken out of the facility. I understand that refusal to submit to a urinalysis, blood test or search, when requested to do so, may result in termination of my employment.
• Compliance with this facility’s Substance Abuse Policy is a condition of employment. This hospital requires that newly hired employee be free of alcohol or drug abuse. Each offer of employment is contingent upon successfully completing a urinalysis test/screen for alcohol and drugs in accordance with hospital policy. Continued employment is also contingent upon compliance with the hospital’s Alcohol and Drug Abuse 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.

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.