SMITH CLINIC / MARION ANCILLARY SERVICES / MARION AREA HEALTH CENTER
Please Read and Initial Each Paragraph Below (if there is any part of this page you do not understand, please ask the interviewer about it before signing).
_________ I hereby authorize Smith Clinic/ Marion Area Health Center/ Marion Ancillary Services to thoroughly investigate my references, work records, education and other matters related to my suitability for employment and, further, authorize my current and former employers to disclose any and all letter reports and other information pertaining to my employment with them, without giving me prior of such disclosure. In addition, I hereby release Smith Clinic/ Marion Area Health Center/Marion Ancillary Services, my current and 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 disclosures.
_________ I understand that if offered employment, the offer may be contingent on my passing a pre-employment drug screen. By signing this application, I voluntarily agree to submit to a pre-employment drug screen , and I understand that failure to pass the drug screen will result in withdrawal of the employment offer.
_________ If hired, I also agree to submit to alcohol and/or drug testing as a condition of employment. I agree that Smith Clinic/ Marion Area Health Center/ Marion Ancillary Services may conduct alcohol and/or drug screening at their sole discretion with or without notice. I also understand that refusal to submit to an alcohol/drug screen may be considered a voluntary resignation of employment, at the sole discretion of the employer.
_________ I understand that nothing contained in the application or conveyed to me during any interview is intended to create an employment contract, implied or explicit, between me and Smith Clinic/ Marion Area Health Center/ Marion Ancillary Services. In addition, I understand and agree that if I am employed, my employment relationship is strictly voluntary and at our mutual will. I understand that if employed, my employment is for no definite period and may be terminated at any time, with or without prior notice, with or without cause or reason, at the option of either myself or Smith Clinic/ Marion Area Health Center/ Marion Ancillary Services, and that no promises or representations contrary to the forgoing are binding on any of the three employers unless made in writing and signed by the Executive Director.
_________ I understand and agree that any future changes in my title, duties, compensation, working conditions, and/or benefits, policies and procedures will not alter our at-will and arbitration agreements.
_________ I understand that if offered employment, I will, as a condition of employment, be required to submit proof of my identity and legal right to work in the United States on my first day of employment.
_________ If the position applied for requires driving in the course of work, I understand that I will be required to possess a current and valid driver's license and understand that I will be required to provide a copy of my official driving record and proof of insurance.
_________ I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement on this application or on any documents used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
My signature below certifies that I have read and understand this complete page, and agree to the terms and conditions outlined in this document.
Applicant's Signature Date