Have you ever been convicted of a crime?

If so, for what, when and where?

Do you consider yourself to be able to perform all the duties required by the job(s) for which you are making an application without endangering yourself, other employees or patients?

If “No” please explain:

By submitting this application, you certify that answers given herein are true and complete to the best of my knowledge. You authorize investigation of all statements contained in this application for employment as may be necessary for arriving at an employment decision.

You hereby acknowledge that any employment relationship with this company is of an “at-will” nature, which means that the Employee may resign at any time and the Employer, may discharge Employee at any time with or without cause. It is further understood this “at- will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of the Company.

In the event of employment, you understand that false or misleading information given in this application or interview(s) may result in discharge. You understand, also, that you are required to abide by all rules and regulations of the employer.