* = Required
PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING THIS APPLICATION FORM.
COLUMBUS COMMUNITY HOSPITAL, INC. (CCH) RESERVES THE RIGHT TO REJECT
ANY APPLICATION WHICH HAS NOT BEEN FULLY COMPLETED.
A NEW APPLICATION WILL BE REQUIRED AFTER 6 MONTHS.
I HAVE READ AND AGREE TO THE ABOVE AND HEREBY CERTIFY THAT THE FACTS THAT I HAVE PROVIDED IN MY
EMPLOYMENT APPLICATION ARE TRUE AND COMPLETE.
By accepting and submitting this application, I understand and agree to the terms and conditions stated above.
- I certify that the information contained in this application is complete and true to the best of my knowledge and that I have not knowingly
withheld any facts or information which would affect my employment. I hereby authorize CCH or an agent of CCH to verify the information
contained herein and to investigate my employment, education, personal history, criminal history, credit history, and motor vehicle
operation history as applicable. In addition, I understand CCH will conduct a check of the Child and Adult Abuse Registry, the Sex
Offender Registry and the OIG and GSA Excluded Parties Listings.
- I understand that prior to my employment, I must pass a physical assessment, which will include a drug/alcohol screen and an
essential functions assessment. I understand that the exam will be provided by CCH. Failure to pass this assessment will be grounds
for denial of employment or termination if I am already employed.
- I also understand that all offers of employment are contingent upon the successful completion of the above items and that discovery
of any falsified, omitted or negative information at any point in time may result in denial of employment or termination if I am
- CCH is tobacco-free. Tobacco use is prohibited on all CCH property.
- In accordance with the Drug-Free Workplace Act of 1988, it is the policy of CCH to provide a safe environment for patients,
employees and visitors. The illegal manufacture, possession, distribution or use of controlled substances by employees in the
workplace is prohibited.
- No person shall be denied employment or equal treatment in the administration of salary, benefits, opportunity for advancement or
any other terms or conditions of employment because of the person's race, color, religion, sex (including pregnancy, gender identity,
and sexual orientation), national origin, age (40 or older), disability or genetic information.
- If employed, I will comply with all rules and regulations for employees of CCH facilities. I understand and agree that neither this
form, nor any other written policy or procedure of CCH and its facilities, shall constitute a contract of employment between CCH
and myself for either a definite or an indefinite period of time. I further understand that if employed, I may resign at any time and
that CCH may terminate or modify the terms and conditions of my employment at any time.
- Integrity, Compassion, Accountability, Respect, and Excellence are Values we hold high here at CCH. If employed, I will commit to
building an environment that will uphold these high standards.
- I understand that any falsification or omission of material and/or information requested may result in denial of employment or
termination if I am already employed. Upon my termination, I authorize the release of reference information on my work and will release
CCH from any liability whatsoever as a result of any such inquiry and factual disclosers.
- I authorize any reference source to provide CCH with any and all information concerning my previous records, any pertinent information
they may have, personal or otherwise, and release parties from all liability for any damage that may result from furnishing to CCH.
- I understand that CCH operates 24 hours a day, seven days a week, and that weekend work or temporary changes of shift may be
required during my employment.
- I hereby give consent to any and all prior employers of mine to provide information with regard to my
employment with prior employers to Columbus Community Hospital.