FMDH Employment Application

The following information is needed by the agency for EEOC reporting purposes. The information below is strictly voluntary. Your assistance in our reporting efforts if greatly appreciated. 

ACKNOWLEDGMENT

1. I understand that if I am being considered for employment by Frances Mahon Deaconess Hospital(the Company), I will be required to submit to a post-offer physical and drug/alcohol testing (which will be paid for by the Company) and to authorize the release of the physical examination results and test results to the Company . Applicants whose test results are positive (prohibited substances present) will not be eligible for further employment consideration.

2. I also understand that as part of my Application for Employment t hat at any time during the course of such employment, I may also be required to be examined concerning my ability to perform any job in a manner t hat does not endanger my own health or safety or the health or safety of others. I hereby authorize all providers of health care who examine me to disclose to my employer or any of its agents, representatives and employees, including attorneys, all medical information revealed during such examinations that impacts my job performance. I understand t his authorization will remain valid for five years from the date of this Application, and that if I become employed this authorization will remain in effect for five years after my employment terminates. I understand that I have the right to receive a copy of this authorization.

3. Any acceptance of employment will be predicated upon the truthfulness of the written and verbal statements contained within this Application and pre-employment process. I understand that should my employer find that any statement I have made is not truthful, any job extended to me may be withdrawn and, if employed, I may be subject to termination. 4. I authorize my employer to make any investigation deemed necessary for employment consideration within the organization.

5. I understand this Application for Employment is not to be confused as a guarantee of employment for a specific time. I further understand that my employment with the Company does not constitute any form of contract, implied or expressed, and such employment will be terminable either by myself or my employer upon notice of one party to the other.

6. I grant my employer approval, after my termination of employment to release information which it may deem appropriate regarding my employment with or termination from the organization, to anyone who has a reasonable basis for making such inquiry. So long as the information disclosed is not known by this organization to be inaccurate, this organization shall not incur legal liability of any nature in connection with the furnishing of such information.

7. I understand that my Application for Employment will be placed in an active status for a period of six months during which time it will be reviewed as job openings occur in my area(s) of job interest. I also understand that should I wish to continue being considered for job openings beyond the six month period, I must reapply by (a) submitting a new Application for Employment or by (b ) submitting a letter requesting renewal of m y Application and including an update of my qualifications (recent work history, educational achievements, etc.).

8. I acknowledge that I have read all of the above statements and that I understand them.

In connection with my application for employment, I understand that Frances Mahon Deaconess Hospital or its agents may conduct background investigations on me. I further understand that these background investigations may include, but are not limited to, criminal histories, driving records, consumer credit reports, job and personal reference reports, education reports, and worker’s compensation reports. I also understand that this information will be requested from various public and private agencies, former employers and other entities, which may have knowledge of my background including claims involving me in the files of insurance companies.

I authorize, without reservation, any party or agency contacted by Frances Mahon Deaconess Hospital or its agents to furnish any of the above mentioned or related information to them. I agree to hold harmless Frances Mahon Deaconess Hospital its agents or individuals or agencies furnishing information for the pre-employment use of such information.

I understand that Frances Mahon Deaconess Hospital has a policy of a drug and alcohol free workplace and that I may be required to submit to a drug/alcohol screening in the following situations: (1) prior to employment, (2) as part of the agency’s random screening program, (3) following an accident, and (4) when a reasonable suspicion exists that I am using or in the possession of drugs or alcohol while on agency property or in agency vehicles. I further understand that failure to comply with this policy, or submit to a required drug/ alcohol screening in any of the above-mentioned situations is grounds for termination.

I hereby certify that all information contained in this application is correct and understand that misrepresentations of any information may be grounds for termination if I am hired. I further certify that I am lawfully entitled to be employed in the United States of America.

**To sign application, drag your mouse to write your signature.**