APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION

I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by Golden Plains Community Hospital (thereinafter referred to as GPCH) that such employment is at will, for no specified duration and may be terminated by either GPCH or myself any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions, and/or statements of GPCH or its representatives used during the employment process is deemed a contract of employment real or implied. I understand that no representative of GPCH except the CEO has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the CEO of GPCH.

In consideration for employment with GPCH, if employed, I agree to conform to the rules, regulations, policies, and procedures of GPCH at all times and understand that such obedience is a condition of employment. I understand that due to the nature of GPCH, attendance and punctuality are considered essential requirements of every job and that poor attendance or tardiness will result in disciplinary action.

I understand that if offered a position with GPCH, I will be required to submit to a pre-employment medical examination, drug screening and background check as a condition of employment. I understand that unsatisfactory results from, or refusal to cooperate with, or any attempt to affect the results of these pre-employment test and checks will result in withdrawal of any employment offer or termination of employment if already employed.

I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to GPCH and/or any representatives, agents, or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information.

I understand that this application is considered current for six months. If I wish to be considered for employment after this period I must complete and submit a new application.

BY ENTERING MY NAME BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD, AND AGREE TO THE ABOVE STATEMENTS.

Respiratory Therapist- PRN

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