PLEASE READ THIS STATEMENT CAREFULLY BEFORE YOU COMPLETE THIS APPLICATION
I understand that if I am employed by FH, Inc., any misrepresentation, falsification or omission on this application is sufficient cause for my dismissal. My continued employment will depend on the successful performance of work assigned to me during my trial period and upon the continued successful performance of work and the further need of my continued employment by FH, Inc. FH, Inc., in considering my application for employment, may verify the information set forth on this application and obtain additional information relating to my background. Provided that state/federal law permits, I further agree to submit to alcohol and/or drug screening tests and polygraph examinations if requested of me at any time prior to or during my employment with FH, Inc.
I understand that health care workers are required by law/regulation/policy to pass certain physicals from time to time. I further understand that if I do not pass any of these required physicals that I will not be able to work for FH, Inc.
I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between FH, Inc. and myself for either employment or for the providing of any benefit. I understand that no oral conversations are promises or guarantees regarding employment and that no such "promise" or "guarantee" is binding upon FH, Inc. If an employment relationship is established, understand that it is not for a stated period of time, but shall be "at will" and may be terminated at will by me or FH, Inc. with or without cause.
If yes, under what name?
Date Last Worked
Reason For Departure
Position For Which You Are Applying?
When Can You Start?
Number of Hours You Would Like to Work Per Week?
— Desired Hours — 5-15 15-30 30-40 40
Shift Preference (First Choice)
— Desired Shift (First Choice) — Morning Afternoon Night
Shift Preference (Second Choice)
— Desired Shift (Second Choice) — Morning Afternoon Night
What/who prompted you to apply here?
List any relatives that work at FH, Inc.
If under 16, can you obtain a permit to work?
— Select One — Yes No Not Applicable
A conviction record will not necessarily be a bar to employment. Factors,such as age and timing of offense, seriousness and nature of the violation and rehabilitation will be taken into account.
— State — Alabama Alaska Arizona Arkansas California Colorado Conneticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming
I certify that the information contained in this application is correct to the best of my knowledge, and understand that any misrepresentation, falsification or omission in this application in any detail is grounds for disqualification from further consideration or for dismissal from employment at the time the company discovers any misrepresentation, omission or falsification. I agree to conform to the rules and regulations of FH, Inc. I understand that if hired I will be hired on the basis of "at will employment", and that my employment and compensation can be terminated with or without cause and with or without notice, at any time, at the option of either the company or myself.
I understand that this application is good only for one hundred twenty (120) days from date of application. If I still desire a position with FH, Inc. after this application expires, it will be my duty to fill out a new application and file it with FH, Inc. Otherwise, FH, Inc. will not consider me for employment after this application expires. I authorize and hold harmless all persons, schools, companies, agencies, corporations, businesses, credit bureaus, law enforcement agencies, and doctors to supply FH, Inc. with any information concerning my background/history.