Current Open Position for Which You Are Applying: Certified Surgical Tech/Surgical Tech (Surgery/Same Day Surgery) - 80 hours
Arrests or charges that have been expunged need not be disclosed.
OIG RELEASE OF INFORMATION
HRMC is strongly committed to the reduction of prospective fraudulent, wasteful, and
abusive activity and to employing and working with individuals and entities that
will not hinder the ability to administer health care coverage to beneficiaries.
As part of this commitment, it is HRMC’s policy to review the OIG’s, LEIE and
GSA’s SAM to ensure that HRMC works and contracts with responsible parties only and
does not allow individual or entities to participate in a Federal health care program
if they have been debarred, suspended, or otherwise excluded from participation.
College #2 (if applicable)
Licensing and Certifications
List any professional licenses, registration or certification you possess (Include Driver's License, if applicable)
Please list all work history from most recent to oldest
Current or Most Recent
Professional References (Other than Relatives)
Give references who have good knowledge of your work.
Please review and acknowledge that you understand the following.
In submitting this application for employment:
* I certify that the information in this application is true and complete for all
practical purposes. It may be verified by the facility. Should
a position be offered and later it is found that the information is significantly
untrue, incomplete, or misrepresented, I understand and agree that the facility
is relieved of all commitments, financial or otherwise pertinent
to employment, and that I am subject to immediate discharge without recourse.
I authorize this employer to thoroughly investigate my
references, work record, education and other matters related to my suitability for
employment, (e.g., motor vehicle operator records, criminal records, school records,
licensure records, etc. ) and further authorize the references I have listed to
disclose to the company and all letters, reports, and other information related
to my work records, without giving me prior notice of such disclosure. In addition,
I release this employer, my former employers and all other
persons, corporations, partnerships and associations from any and all claims, demands
or liabilities arising out of or in any way related to such investigation or disclosure.
I UNDERSTAND AND AGREE THAT ANY POLICIES WHICH I MAY RECEIVE WILL NOT CONSTITUTE AN EMPLOYMENT CONTRACT.
Compliance with this facility's Substance Abuse Policy is a condition of employment.
This hospital requires that every newly hired employee be free of drug
abuse. I understand and acknowledge that I may be required to submit to a physical
examination, including drug testing. I hereby authorize the release
of the results of such an examination to this employer
for their use in evaluating my suitability for employment. Further, I release the
examining facility and this employer from any and all liability,
and from any damage that may result from the release of such information. Each offer
of employment is contingent upon successfully completing a urinalysis test/screen
for drugs in accordance with hospital policy.
* I UNDERSTAND AND AGREE THAT IF I AM OFFERED EMPLOYMENT BY THE FACILITY, MY EMPLOYMENT
WILL BE FOR NO DEFINITE TERM AND THAT EITHER I, OR THE FACILITY WILL HAVE THE RIGHT
TO TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT CAUSE, AND
WITH OR WITHOUT NOTICE, I ALSO UNDERSTAND THAT THIS STATUS CAN ONLY BE ALTERED BY
A WRITTEN CONTRACT OF EMPLOYMENT WHICH IS SPECIFIC AS TO ALL MATERIAL TERMS AND
IS SIGNED BY ME AND THE ADMINISTRATOR OF THE FACILITY.
I hereby authorize any prior employers to provide such information concerning my
employment with them as may be requested, and also authorize the Registrar/Placement
Office of all educational institutions attended to release an official copy of my
transcript and, if available, faculty appraisals. I also authorize any appropriate
licensing board to release full information concerning my license status and my
By submitting this application,
I agree that all of the preceding questions
are answered truthfully and to the best
of my abilities.