APPLICATION FOR EMPLOYMENT

I understand that it is a policy of The Physicians Spine & Rehabilitation Specialists to do a pre-employment and/or random drug screen(s) on all prospective and/or current employees.

I further understand that if I do not disclose all prescription medications, over the counter vitamins and herbs as well as any other supplements that I am currently taking and my drug screen is positive, it may affect my eligibility for and/or continuation of employment.

I also understand that passing the mandatory drug screening does not ensure a position with the Physicians Spine & Rehabilitation Specialists.

I have disclosed all medications, herbs, vitamins and other supplements that I am currently taking to the best of my knowledge. This information will remain confidential in my health file or will be destroyed with my application, as applicable.

1) I certify by my signature that the information have given on this application is true and complete. I understand that any concealment or misrepresentation may be considered cause for termination of employment. I authorize inquiry into the statements made in this application as may be necessary I reaching an employment decision.

2)  I also certify that I may be required to work at other than my regular assignment and hours, including but not limited to overtime, as the needs of the organization require, and that my continued employment is subject to complying with those other rules, regulations, and conditions as established by management.

3)  I also certify that if I am employed, I will give at least 14 days written notice before terminating my employment. Failure to give such notice waives any and all benefits I accrued other than pay for time worked as allowed by applicable employment law.

4)  I understand that for the organization and its personnel to make a knowledgeable decision as to my being hired, they must check with my prior employers. I consent to and authorize the organization and its personnel to ask any and all of the references I note above, in any manner they choose, for information concerning me whether good or bad, and I know that a complete answer is important to my being hired.

5)  I understand that I will be required to abide by the Policies and Procedures of the organization including but not limited to personnel policies and procedures, which may be revised at any time by management with or without notice.

6)  I understand that my employment will be ‘employment at will’, which means that the employee may resign at any time and the employer may discharge the employee at any time, with or without cause. I also understand that no one representing the organization may change this employment status unless it is in writing and signed by the Administrator.

7) I understand that I may be required to pass a physical examination, including a drug test, before a final offer of employment is made. Random drug testing may also be required at any time throughout my employment. By signing below, I consent to these procedures.

8)  I understand that in applying for employment, an investigative report may be made by a consumer reporting agency and/or law enforcement agency to include but not limited to information concerning character, general reputation, personal characteristics, criminal records and mode of living, as applicable. If such an investigative report is made, I will receive notice that a report has been requested. I have the right to make written request for a complete and accurate disclosure of additional information concerning the nature and scope of this investigation.

9)  I understand that my application will remain on file for a period of sixty (60) days. After that time, it will be necessary to complete a new application for employment consideration with the organization.