A conviction record will not necessarily disqualify an applicant from employment: the circumstances of the
conviction will be considered in relation to the nature and duties of the job applied for.
The law requires that you provide evidence and a sworn statement of your citizenship or work authorization if
you are hired. Any offer of employment which you received is contingent upon your providing the documentation and
statement which we will request from you.
EDUCATION AND TRAINING
If you are a veteran of the armed forces of the United States, please provide the following information:
A less than honorable discharge will not automatically disqualify you from employment.
Please list three personal references, other than prior employers or relative, whom we can contact.
HODGEMAN COUNTY HEALTH CENTER
Name of Applicant
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 and agree to all of the conditions and statements set forth above, and throughout this application.
AUTHORIZATION FOR RELEASE OF INFORMATION
Hereby authorize the release and disclosure of information to Hodgeman
County Health Center, Jetmore, Kansas, my prospective employer, concerning my employment with your company.
Further, upon written request by Hodgeman County Health Center to my former employer(s) and any other necessary
contacts, I hereby authorize the release said companies, schools, persons from all liability for any damage for issuing
this information concerning my employment and background:
- Date of employment
- Pay level
- Job description and duties'
- Wage history
- Written employee evaluations, which were conducted prior to my separation from employment. (I understand that I may receive a copy, upon request.)
- Whether I was voluntarily or involuntarily released from service, and the reason for the separation; and
- The date of termination
- Credit verification
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.