Application for Employment - Page 1 of 5

EMPLOYMENT IS DEPENDENT UPON SATISFACTORILY PASSING A PHYSICAL EXAMINATION TO ENSURE YOU ARE FULLY CAPABLE OF PERFORMING THE NEEDED WORK.

APPLICANT PLEASE READ CAREFULLY BEFORE SIGINING.

My signature below indicates that I have read, I understand, and I agree to the following:

1. I hereby certify that the information I have provided in this employment application is true and complete. I understand and accept that there will be no consideration of this application to the extent that I fail to supply job-related information, such as unexplained gaps in my employment history. I understand that if I am hired, the discovery of any false information provided or any relevant information omitted (no matter when discovered) will result in the termination of my employment.
2. I authorize and instruct Jersey Shore Hospital to make whatever inquiries are necessary of any person or organization who is not a consumer reporting agency to verify any information I have provided in this application and to determine my qualifications and abilities, for the position(s) sought.
3. Additionally, as a part of Jersey Shore Hospital’s procedure for processing employment applications, there may be a job-related investigation and/or a report made by a consumer reporting agency. Information may be obtained through interviews with third parties, such as family members, business associates, financial sources, friends, neighbors, or others who know me. This inquiry may include informatin concerning my character, work habits including reasons for past terminations from employment general reputation, personal characteristics, and mode of living, to the extent they bear on my ability to perform the essential functions of the job(s) sought by me. I authorize and encourage Jersey Shore Hospital to conduct such an investigation and/or have such a report made and to make whatever inquiries it considers necessary in connection with my application for employment or in the course of review of my employment. I authorize and encourage all persons, schools, or organizations, including, without limitation, companies, corporations, credit bureaus, departments of motor vehicles, and law enforcement agencies, to supply job-related information concerning my background to Jersey Shore Hospital and its agents. I release Jersey Shore Hospital, its employees and agents, and all persons who provide information concerning me to Jersey Shore Hospital, its employees or agents, from liability for any damages arising out of supplying, receiving, or acting upon such information.
4. In exchange for Jersey Shore Hospital’s agreement to receive, process and consider my application for employment, I hereby release Jersey Shore Hospital and any and all persons or organizations contacted by Jersey Shore Hospital from any and all claims or causes of action arising out of Jersey Shore Hospital’s verification of the information I have provided in this application and/or its determination of my qualifications and abilities.
5. I understand and accept that this application will apply only to the position(s) sought by me at this time and that I need to submit another application if I seek future vacancies, including those for the position(s) sought at this time.
6. I understand and accept that, if hired, Jersey Shore Hospital may provide me with use of its property, including, for instance, a desk, locker, telephone, pager and/or computer hardware and software. To ensure that this Hospital property is used only for business purposes and not in violation of Hospital policy, I understand and accept that such equipment remains Hospital property, to be used only for legitimate business, and that they may be subject to announced or unannounced searches, including any electronic mail or voice mail created or received by me.
7. I understand and accept that if an offer of employment is made to me, it shall be contingent upon my completion of a post-offer pre-placement physical examination to the satisfaction of Jersey Shore Hospital. I hereby consent to undergo that physical examination which may include any and all tests and procedures determined by Jersey Shore Hospital to be helpful in evaluating my suitability for employment, including, without limitation, blood tests, urinalysis, x-rays, hair, controlled substance and/or alcohol testing.
8. I understand and accept that employment at Jersey Shore Hospital continues as long as the employee and Jersey Shore Hospital both wish it to continue. I understand and accept that, if I am hired by Jersey Shore Hospital, either I or Jersey Shore Hospital may terminate my employment at any time for any or no reason, except as otherwise agreed, in writing, by Jersey Shore Hospital. I further understand and accept that any modification of this arrangement must be reduced to writing and signed by me and an authorized representative of Jersey Shore Hospital.

My signature (by selecting "yes") below indicates that I have read, I understand, and I agree to what I have just read.

YES NO

Thank you for completing your application for employment with Jersey Shore Hospital. Jersey Shore Hospital may obtain investigative consumer reports about you from one or more consumer reporting agencies. Any such report will be used for employment purposes in connection with your application for employment and/or in connection with any subsequent periods of employment if Jersey Shore Hospital decides to hire you. Such investigative consumer reports may contain information concerning your character, work habits (including reasons for termination from past employment), general reputation, personal characteristics and mode of living, obtained, in part, through personal interviews with neighbors, friends, associates, or others you know or who may have such knowledge.

Under the Federal Fair Credit Reporting Act, you have the right to obtain,upon request, a complete and accurate disclosure of the nature and scope of the investigation and a summary of your rights under the Fair Credit Reporting Act. Your request for this additional information must be made, in writing, to Jersey Shore Hospital. Jersey Shore Hospital will send you this requested information within (5) days from its receipt of your written request or five (5) days from when it first requested the investigative consumer report, whichever is later.

CONSENT TO OBTAIN INVESTIGATIVE CONSUMER REPORT

I acknowledge receipt of the above Notice. I have read and fully understand the contents of the Notice, and I authorize Jersey Shore Hospital to obtain investigative consumer reports about me. I understand and acknowledge that Jersey Shore Hospital's analysis of any such report may affect whether it offers employment to me, and, if hired, Jersey Shore Hospital may use it in connection with future decisions concerning my employment. I consent to Jersey Shore Hospital's use of such reports for these purposes.

My signature (by selecting "yes") below indicates that I have read, I understand, and I agree to what I have just read.

YES NO