Acknowledgement

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. Clay County Hospital reserves the right to confer with persons listed by you as a reference, or with any other individuals, with knowledge concerning your total qualifications for the position. The Hospital will not inquire into your financial status, religious affiliation, marital status, or on other matters unrelated to your qualifications to fill the position for which you applied. You agree to submit to a criminal background investigation upon conditional offer of employment. Information received from such inquiries will be used solely for determining your employability with Clay County Hospital and for no other purpose. This information will not be shared with anyone other than those Hospital representatives involved in the selection process. Unless you are willing to authorize Clay County Hospital to make such inquiries, your application will not be considered. I hereby consent to having Clay County Hospital contact anyone that it deems appropriate to investigate or verify any information I have given or to discuss my background, past performance, or suitability for employment. I further consent to being discussed by any person so contacted and I waive all rights to bring any action for defamation, invasion of privacy, or any similar cause against anyone contacted as a result of what he or she may say about me. I understand that Clay County Hospital has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment. Consent to and compliance with such policy is a condition of my employment. I understand that this document is not an offer of employment, and that an offer of employment, if tendered, does not constitute a contract for continued guaranteed employment. I understand that staff employees of Clay County Hospital serve at-will, and the employment relationship may be terminated at any time by either party, for any or no reason, other than a reason prohibited by law. If employed, I will be required to furnish proof of eligibility to work in the United States. If employed on a regular, benefits-eligible basis, I understand that I will be required to make mandatory contributions to the Illinois Municipal Retirement Fund (IMRF). I understand that any benefits I receive may be subject to change or discontinuation at any time without prior notice. Clay County Hospital is a tobacco free campus. Clay County Hospital, in accordance with state and federal laws, does not discriminate on the basis of race, color, religion, sex, age, national origin, veteran status, sexual orientation, gender identity, disability, or any other basis of discrimination prohibited by law.

CRT/RRT

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