PERSONAL INFO
CONTACT INFO
APPLICATION DETAILS
COLLEGE
UNIVERSITY
HIGH SCHOOL
TECHNICAL OR VOCATIONAL SCHOOLS
PROFESSIONAL LICENSES
HAS YOUR LICENSE OR REGISTRATION EVER BEEN SUSPENDED, REVOKED OR ON PROBATION?
PROFESSIONAL CERTIFICATIONS
LENGUAGE
ENGLISH
SPANISH
PREVIOUS EXPERIENCE
PREVIOUS EXPERIENCE
PREVIOUS EXPERIENCE
REFERENCE 1
REFERENCE 2
CAREFULLY READ THIS SECTION PRIOR TO PROVIDING SIGNATURE BELOW
I hereby affirm that the information provided on this application ( and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in
discharge even if discovered at a later date.
I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug
screening as a condition of employment.
I hereby authorize persons, schools, my current employer (if applicable), and previous employers and other organizations to provide this facility and its affiliates
with any requested information regarding my application or suitability for employments, and I completely release all such persons or entities from any and all liability
related to the providing or use of such information.
I understand that this authorization shall be valid for this and any future reports that may be requested.
I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice,
and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for a written
agreement signed by an administrative representative of this facility and notarized.
SIGNATURE
DATE
All information provided will be public record and will be released upon request, unless exempt or confidential.
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