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APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION

RECORD OF EMPLOYMENT

1. Current/Most Recent Employer

Dates Employed:

2. Next Previous Employer

Dates Employed:

3. Next Previous Employer

Dates Employed:

EDUCATION

HIGH SCHOOL

COLLEGE/TECHNICAL SCHOOL

GRADUATE STUDIES

OTHER INFORMATION

NOTE: Answering "Yes" to these questions does not constitute an automatic bar to employment. Do not include minor traffic violations, convictions for which the record has been sealed or expunged or cases that have been judicially dismissed.

EMPLOYMENT DISCLOSURE

FAIR CREDIT REPORTING ACT DISCLOSURE

As an applicant for employment or an employee of this company, you have rights under the Fair Credit Reporting Act (FCRA). By this document, this company discloses to you that a consumer report may be obtained for employment purposes as part of the pre-employment background investigation and at any time during your employment, if you are hired. If this company obtains a consumer report about you, and if this company considers any information in the consumer report when making an employment related decision that directly and adversely affects you, this company will provide you with a copy of the consumer report and a summary of your rights under the FCRA before the decision is finalized. You also may contact the Federal Trade Commission about your rights under the FCRA.

AUTHORIZATION

By submitting this application, I acknowledge that I have received the foregoing disclosure that this company may obtain a consumer report as part of its pre-employment background investigation and/or during the course of my employment, if I am hired. By submitting this application, I voluntarily authorize this company to obtain consumer reports about me and to consider the consumer report in its pre-employment background investigation and/or when making decisions during the course of my employment, if I am hired. I understand that I have rights under the Fair Credit Reporting Act, including the rights discussed above.

EMPLOYMENT DISCLOSURE

All qualified applicants will receive consideration for employment without regard to sex, race, color, national origin or ancestry, age or disability. No information on this application will be used for the purpose of discrimination. Submitting this application certifies that my answers to the forgoing questions are true and correct and that I understand that intentionally false information will result in refusal of employment or termination of employment if discovered after the date of hire. I understand that, if hired, my status is that of an employee at will, meaning that I have no contractual right, express or implied, to remain in this company's employ. In consideration of my employment, I specifically agree that my employment or the terms and conditions thereof including compensation can be changed or terminated with or without cause and with or without notice at any time at the option of this company. I further understand that, if hired, my employment is for no definite period and either this company or I may terminate our relationship at will at any time and that this employment application does not constitute an employment contract. It is further agreed that this "at will" employment relationship may not be changed by any written document or by conduct, unless such change is specifically agreed and acknowledged in writing by an authorized executive of this organization. I voluntarily grant this company the right to investigate and verify the information and statements I have provided in this application and agree to hold all persons harmless with respect to any information they may give, receive or verify. I agree that, if hired, I will observe all policies and strict confidentiality concerning all affairs of this company and its members. If you are asked to be interviewed, you will sign the application at that time.

Please email a PDF copy of cover letter and resume to springhursthosp@bellsouth.net.

By submitting this application, I affirm that I have read and agree to all the disclosures and conditions included in the on-line application.