Application

Employment Desired

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Personal Information
List any relatives who are currently employed by our facility:
Employment Record
Employer I
Employer II
Employer III
Education History
High school
College I
College II
College III
Professional Licensure, Registry, Certification

The state of Florida regulations and the mandate of the accrediting organization, American Osteopathic Association require that all registered, license and certified employees show proof of same to his/her employer. Copy required upon employment.

License I
License II
License III
Office skills
Foreign languages
Language I
Language II
Language III
Resume upload
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Certification of Agreement

I certify that the information contained in this application is correct to the best of my knowledge and understand that any falsification, misrepresentation or omission on this application is grounds for refusal to hire, or if hired, dismissal. I authorize any of the persons or organizations referenced in this application to give the Hospital any and all information concerning my previous employment, education or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application and release of such parties and the Hospital from all liability for any damage that may result from furnishing such information. I further authorize the Hospital to conduct any background investigation(s) they deem necessary, I authorize the Hospital to request and receive such information.

• If employed, I understand that I will be an employee "at will" and either the Hospital or I may terminate my employment relationship at any time with or without notice for any reason not violative of the law.

• I agree to comply with the Hospital rules, regulations and policies, and acknowledge that these rules, regulations and policies may be changed, interpretation withdrawn, or supplemented any time and without prior notice to me.

• I acknowledge that any offer of employment, or my acceptance of an employment offer, if such is to occur, may be withdrawn with or without cause and with or without prior notice at any time, at the option of the Hospital or myself. I understand that this application and any other documents which I may receive are not contracts of employment. I further understand that no representative of the Hospital other than an officer has any authority to enter into any agreement for employment for any specified period of time or to assure any other personnel action, either prior to commencement of employment or after I have become employed, or to assure any benefits or terms and conditions of employment, or make any agreement contrary to the foregoing.

• I agree to have a physical examination, including a drug screen, as required for my position and understand that any offer of employment is contingent upon my passing this physical examination.

Signature
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