MT/MLT

I CERTIFY THAT MY ANSWERS ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. IF EMPLOYED, I ACKNOWLEDGE AND UNDERSTAND THAT:

• • Any misstatement or omission of fact on this employment inquiry may result in my dismissal.


• • If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.


• • I must submit acceptable evidence of my right to work in the United States.


• • CCMC facilities are tobacco, drug and alcohol free workplaces. I must take and pass a pre-employment and drug test that screens for illegal drugs, alcohol, and unauthorized controlled substances; remain free of illegal drugs, alcohol and abusive levels of prescription drugs at work; and comply with the Drug-Free and Tobacco-Free policies.


• • I will be required to comply with all Administration policies and procedures.


• • I authorize this employment inquiry to be viewed by any affiliated companies.


• • I am required to report any known or suspected practices that may violate state or federal law, including, but not limited to Medicare fraud and abuse. I understand that I am required to report such conduct to Human Resources or the CEO.


• • I understand that Comanche County Medical Center is an employer at will, which means that my employment is not for a definite term and that either CCMC or I will have the right to terminate the employment relationship at any time, with or without cause or notice. I also understand that this status can only be altered by a written contract of employment that is specific as to all material terms and is signed by the CEO of CCMC and myself.


• • Upon termination, I will return in good condition any company property issued to me or to allow for the value of same, plus any outstanding accounts, to be deducted from my wages.


• • I agree to notify CCMC in writing within forty-eight (48) hours of receiving any written or oral notice of any adverse action, including, without limitation, exclusion from participation in any federal or state health care or procurement programs, any filed and served malpractice suit or arbitration action; any adverse action by a state licensing board; any adverse action which has resulted in the filing of a report with the state licensing board; any revocation of DEA license; a conviction or charge of any felony, misdemeanor or deferred adjudication; any action against any certification under the Medicare or Medicaid programs; or any cancellation, non-renewal or material reduction in medical liability insurance policy coverage.


• • I hereby authorize CCMC to confirm the information that appears in this employment inquiry and authorize all former employers, universities or colleges, references, credit and government agencies, or other persons, firms, corporations and institutions to provide such information to CCMC without delay.

As required by the Fair Credit Reporting Act, notice is given that a consumer report may be made in connection with your employment inquiry. A
consumer report may consist of employment records, educational verification, license verification, driving history, previous addresses or other public
records relative to criminal charges. A credit report will not be requested unless it is deemed pertinent to the functions of the position for which you are
inquiring. If you are denied employment, either wholly or partly, because of the information contained in a consumer report, a disclosure will be made to
you of the name and address of the consumer reporting agency making such a report.