Employment Form

EDUCATION:

PREVIOUS EXPERIENCE:

REFERENCES:

Please answer the following:

Medicine Lodge Memorial Hospital and Physicians Clinic is an equal opportunity employer regardless of race, color, religion, creed, sex, marital status, national origin, disability, age, veteran status, on-the-job injury, sexual orientation, political affiliation, or belief. Employment decisions are made without consideration of these or any other factors that are prohibited by law.

Employment is dependant upon satisfactorily passing a pre-employment physical, as well as a pre-employment drug screen. I hereby certify that the foregoing statements are true and correct to the best of my knowledge, and hereby grant Medicine Lodge Memorial Hospital and Physicians Clinic permission to verify such statements. I understand that any omissions, misrepresentations, or false statements on this application or in subsequent interviews may be considered as sufficient cause for rejection of this application, or for dismissal if such statements are discovered subsequent to my employment. I understand that a reference check will include, but not be limited to the above references and my previous employers, and I release all parties from all liability for any damage or claim that may result from furnishing Medicine Lodge Memorial Hospital and Physicians Clinic with any information they may have, personal or otherwise.

I hereby acknowledge that I have read and agree to the above statement.*