Work Experience

Education

Professional/Technical Applicants ONLY

Professional References

Additional Information

APPLICANT AUTHORIZATION AND RELEASE

(READ THE FOLLOWING CAREFULLY AND INDICATE YOUR ACCEPTANCE BELOW)

I certify that the information contained in this application is correct to the best of my knowledge and understand that any falsification, misrepresentation or omission on this application is grounds for refusal to hire, or if hired, dismissal. I authorize any of the persons or organizations referenced in this application to give the Southwest Surgical Center (SSC) any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the subjects covered by this application and release all or such parties and the SSC from all liability for any damage that may result from furnishing such information. I authorize SSC to request, receive and use such information and release SSC from any liability regarding the use of such information. I specifically waive any written notice provisions required by state or federal law. Further, I understand and agree that SSC and / or any affiliate may conduct an investigation into criminal history, past employment, education records, Medicare / Medicaid Fraud check and agree to cooperate in any investigation and release all of such parties and SSC from all liability for any damage that may result from furnishing such information. These investigations will not take place until an offer of employment has been made to the candidate. Additionally, SSC may, through a testing service of its choice, collect a blood, urine, hair, saliva or breath sample from me and conduct necessary medical tests to determine the presence or use of drugs and / or alcohol, including controlled substances. I hereby release SSC and its employees from any liability arising out of such test and agree to be bound by its results. I agree that the test results and other relevant medical information may be released to SSC for appropriate review. I also understand that if I refuse to execute this consent, I will not be considered for employment with SSC. If I am accepted for employment with SSC, I agree to comply with its Drug Free Workplace Policy. I understand that my employment is contingent upon successfully completing any background check or post offer physical exam.

I understand and agree that this application for employment and any of the investigations conducted regarding my application may be shared with any other members of SSC and / or its Affiliates for other employment opportunities.

I agree to comply with SSC rules, regulations and policies and acknowledge that these rules, regulations and policies may be changed, interpreted, withdrawn, or supplemented any time and without notice to me. I understand that I am required to follow all policies, procedures, rules or regulations of SSC and / or its Affiliates and that any violation may result in disciplinary action including termination of my employment.

I understand that I must be willing and able to rotate shifts.

I acknowledge that any offer of employment, or my acceptance of an employment offer, if such is to occur, may be withdrawn, with or without cause, and with or without prior notice, at any time, at the option of SSC or myself. I understand that this application and any other documents, which I may receive, are not contracts of employment. If employed, I understand that I will be an employee “at will” and either SSC or I may terminate my employment relationship at any time with or without notice for any reason not in violation of the law.

I further understand that no representative of SSC other than a leadership team member has any authority to enter into any agreement for employment for any specified period of time or to assume any other personnel action, either prior to commencement of employment or after I have become employed, or to assure any benefits or terms and conditions of employment, or make any agreement contrary to the foregoing.

I recognize that in compliance with federal law, all persons hired will be required to verify identity and eligibility to work in the United States and to complete the required employment eligibility verification form upon hire.

Qualified applicants will be considered for vacancies without regard to race, color, religion, national origin, sex, disability, age, or any other characteristic protected by law.

Please indicate below to certify your understanding of and agreement with the preceding Applicant Authorization and Release provisions, enter today’s date, and your full legal name signature in the spaces provided.