By signing below, I certify that the answers and information set out above are true (and accompanying resume, if any), or in the interview(s) is true, accurate and complete to the best of my knowledge. I acknowledge that if any answer or information is not true, accurate or complete, I may not be hired, or if hired, I may be discharged. I voluntarily and knowingly authorize Hodgeman County Health Center to investigate all statements contained in this application for employment and to investigate my character and qualifications. I authorize my prior employers, references, and other with information regarding my work or investigation of my education history or my character, to provide Hodgeman County Health Center with all requested information and references, and to cooperate fully with the investigation of my character and qualifications.
I voluntarily and knowingly authorize any present employer or supervisor, pat employer or supervisor, college, university of other institution of learning, administrator, private business, personal reference and/or other persons to give records or information they may concerning my earnings history, health, character and employment records or any other information requested Hodgeman County Health Center. I authorize the investigation of all statements provided during the process of this application. I voluntarily and knowingly, unconditionally release any unnamed informant from any and all liability resulting from the furnishing of this information. This authorization shall be valid one year from the date signed and a photographic or faxed copy of the authorization shall be as valid as the original.
I realize that as condition of employment, I will be required to show original documentation of both identity and eligibility to work I the United States.
I understand that this application is not a contract of employment. I also acknowledge that no oral representations have been made, and that no one within Hodgeman County Health Center has the authority to make oral contracts of employment. If hired, my employment relationship with Hodgeman County Health Center is terminable at-will, with or without cause, by either myself or Hodgeman County Health Center.
I also understand that in the event I am offered a position with Hodgeman County Health Center, employment is contingent upon my passing a background check, adult and child protective services check, the sexual offender registry, drug test, tuberculosis test and a physical examination which is administered by a health care professional selected by Hodgeman County Health Center, to which I hereby consent
I understand that you are protected in providing this information under the Kansas House Bill 2029, effective 7/1/95 (1995 L. CH. 122)
A photostatic or telefacsmile copy of this authorization shall be considered as effective and valid as the original.
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