Employment Form Test

ACKNOWLEDGEMENT: It is the policy of Coplin Health Systems to provide equal employment opportunity to all qualified persons without regard to citizenship, race, color, creed, religion, gender, sexual orientation, age, national origin, marital status, disability, or veteran status. This application will be given every consideration, but its receipt does not imply that there are any open positions or that the applicant will be employed. Only applicants meeting the minimum requirements for a position as determined by the company will be considered for employment. Should more than one qualified person make application, the company reserves the right to select the applicant that, in its opinion, possesses the best qualifications. In making this application for employment an investigative consumer report may be prepared whereby information is obtained through personal interviews with neighbors, friends, or other acquaintances. Such an inquiry would include information as to character, general reputation, personal characteristics, and mode of living of the applicant. An applicant has the right to make a written request within a reasonable period of time to receive additional detailed information about the nature and scope of this investigation.

AUTHORIZATION: Please read carefully before signing. I authorize investigation of all statements contained in this application (if I am considered for employment) and hereby authorize previous employers, personal references named, or any other person or persons to whom Coplin Health Systems may refer, to give any and all information regarding my background if requested. If employed, I agree to engage in no outside activity which would involve a material conflict of interest with, or which could, as determined by Coplin Health Systems, reflect adversely on the company. If employed, I agree to maintain confidentiality regarding any information concerning the company that may come to my knowledge. Further, I agree to comply with all of the policies and regulations of Coplin Health Systems as set forth in the company’s employee handbook or other communications distributed to all employees. I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Coplin Health Systems to hire me. I understand that if employment is offered to me, either verbally or in writing, such offer does not constitute a contract of employment. I understand that if I am employed by Coplin Health Systems, my employment will be for no definite period of time and that my employment can be terminated at any time and for any reason, with or without cause and without prior notice, at the option of either the company or myself. I also understand that this status can only be altered by a written contract of employment, specific to all material terms, that is signed by an authorized officer of Coplin Health Systems. I attest with my signature below that I have read all of the above statements and understand the same and that all statements made by me are true and accurate to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that any false statements or material omissions may be grounds for refusal to hire, or for immediate dismissal. I certify that I am at least 18 years of age and am legally authorized to work in the United States. Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between myself and Coplin Health Systems for either employment or for the providing of any benefit. I understand that as a condition of this application and any employment, I may be required to submit to testing for the presence of illegal drugs. I hereby consent to such testing. I further acknowledge that no promise or guarantee is binding upon Coplin Health Systems unless made in a written contract of employment as described above.

THIS APPLICATION IS VALID ONLY FOR 1 YEAR FROM THE DATE SIGNED/DATED ABOVE.