Application For Employment

PLEASE NOTE: It is important that you complete all parts of the application. If your application is incomplete or does not clearly show the experience and/or training required, your application may not be accepted. If you have no information to enter in a section, please write N/A. Applicant may be tested for illegal drugs.

High School

College or Business/Trade/Professional School

PLEASE READ CAREFULLY

APPLICATION FORM WAIVER

In exchange for the consideration of my job application by Fountain Health Services Inc (hereinafter called “the Company”), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relation, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment or to confer any right to remain an employee of Fountain Health Services Inc, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a wriSen instrument signed by the CEO/Administrator. Both the Company and I may end the employment relationship at any time without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise its benefits, policies, and procedures, and such changes may include reduced benefits.

I authorize the investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others and release the Company from any liability due to such a contract.

I also understand that (1) the Company has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I understand that continued employment may be based on completing job-related physical examinations.

I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information on my credit records, character, general reputation, personal characteristics, and mode of living. Upon my written request, the Company will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I understand that my employment with the company shall be probationary for sixty (60) days. Further, at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will by either party.

I certify that all answers and statements on this application are true and complete to the best of my knowledge.

This company is an equal employment opportunity employer. We adhere to the policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age, or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and your interest in our agency.