Step 1 of 7 14% My InformationName First Middle Initial Last Have you ever worked under a different name(s)?SelectYesNoIf yes, please list other namesAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email PhoneWhat position are you applying for? (Review job description to ensure you have the necessary qualifications)How did you hear of this / these positions?InternetAdvertisementFriendEmployeeIf employee, please list name Please attach your cover letter and resume or CV*Accepted file types: pdf, doc, Max. file size: 50 MB. Work ExperienceWork Experience Company Name Actions Edit Delete There are no Employers. Add Employer Maximum number of employers reached. EducationEducation Name of School Actions Edit Delete There are no Schools. Add School Maximum number of schools reached. Professional/Technical Applicants ONLYLicense/Regisration Name of license/certification: Actions Edit Delete There are no License/Regisrations. Add License/Regisration Maximum number of license/regisrations reached. Professional ReferencesReferernces Name Actions Edit Delete There are no References. Add Referernce Maximum number of references reached. Additional InformationAre you legally eligible to work in the United States?YesNo(If you are hired, you will be required to provide documentation proving your eligibility to work in the United States)Have you ever been sanctioned by the Office of Inspector General of the Department of Health and Human Services (OIG/HHS) or the Government Services Administration (GSA) or excluded or suspended from participation in any federal or state health care program?SelectYesNoIf yes, please explain the nature of the incident, when and where this incident took place, and the outcome2. Do you have any relative(s) working for Southwest Surgical Center? Yes No If yes, please list their names and relationshipsAre you able to perform the essential functions of the job, based on the position description provided, that you are applying for?SelectYesNo 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. Consent* I understand and agree with the information on this releaseFull Legal Name First Last Today's Date