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APPLICATION FOR EMPLOYMENT

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This application is the property of Mid-Delta Health Systems, Inc.

This application complies with all applicable federal and state laws prohibiting discrimination in hiring or employment practices on the basis of citizenship, race, color, religion, gender, age, national and ethnic origin, disability, or veteran status. Information obtained through this application will be used solely to determine qualifications and suitability for employment. We may also have an option of conducting pre-employment screening when a job offer is made. This application will remain active for one year.

Personal Information

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EDUCATION AND TRAINING

Employment Eligibility Information

SPECIAL SKILLS/KNOWLEDGE

Applicant Statement

I verify that the information I have provided in this application (and on an accompanying resume, if any) is true and complete to the best of my knowledge. I understand that any falsified, misrepresented, incomplete, or omitted information may disqualify me from consideration for employment or result in my dismissal from employment when discovered.

I understand that nothing contained in this employment application, or in granting an interview, is intended to create an expressed or implied contract between the company and me. No promises regarding my employment or duration of employment have been made to me.

I understand that any offer of employment will be conditioned upon successful completion of a number of pre-employment requirements including, if applicable, a pre-employment drug screening, a health statement (post-offer), verification of credentials, experience, attendance at a general orientation program, and any other requirements specified by the company. I understand that if any employment relationship is established, the company has the right to terminate the relationship at any time for any reason or for no reason.

By submitting this application, I authorize the company and its representatives to investigate and verify any and all of the information contained in the employment application, including criminal background and inquiry into the OIG (Office of Inspector General) sanction list. I also authorize all previous employers, schools, organizations and individuals listed herein to verify any and all information I have provided and to give any additional information in response to reference questions intended to determine my suitability for employment. I hereby release all investigators, previous employers, schools, organizations, individuals, and the Company from any liability for providing or receiving such information.

I understand and agree that if I am hired by the Company, that I shall not at any time during or after employment disclose or use any personally identifiable information, I may have been privileged to while I was employed. I also agree that in the event of my separation from employment, I shall return all property belonging to the Company. I hereby instruct the Company to withhold the costs of any non-returned equipment from my payroll.

I agree and understand that if I am hired by the Company, I shall follow all directives, policies, procedures, instructions, laws, accreditation standards, regulations and corporate compliance programs in the performance of my job. If there is something that I do not understand, I am to seek help.

A copy of this document has the same effect as an original document.

My electronic submission of this document shall be deemed to be a valid and legal signautre as if it were signed in ink.