(Proof of identity and eligibility will be required upon employment)
(If no, you may be required to provide authorization to work.)
Days and Hours available: (If employed, notification must be provided in writing should availability change.)
Include start and end date of time frame and the reason why you were not working.
Vocational or Trade School
(Omit any which reflects your race, color, religion, age, sex, sexual orientation, marital status or disabilities.)
Start with your current or most recent position
Personal Reference 1
Give three references (not relatives or employers)
Personal Reference 2
Personal Reference 3
Equal Opportunity Employer Statement
We are an equal opportunity employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, or any other characteristic protected by law.
IMPORTANT, PLEASE READ AND SIGN
I understand that failure to reveal any prior employer, or giving false or misleading information by me on any part of this Application for Employment can result in disqualification for employment consideration or, if hired, may be grounds for termination from the company or its subsidiaries. I understand that if I am hired, my employment is for no definite time and may be terminated at any time without prior notice.
Background Check Disclaimer
By signing below, I authorize Fairfield Hospital District/dba Freestone Medical Center, (also referred to as “the Company” for the purposes of this agreement), to order my background check, including investigative consumer reports. I understand that, as allowed by law, the Company may rely on this authorization to order additional background reports without asking me for my authorization again at any time during my employment.
I also authorize all of the following to disclose to the consumer reporting agency and its agents all information about or concerning me, as allowed by law, including but not limited to: my past or present employers; learning institutions, including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; all other private and public sector repositories of information; and any other person, organization or agency with any information about or concerning me. The information that can be disclosed to the consumer reporting agency and its agents, as allowed by law, includes but is not limited to: information concerning my employment and earnings history; education; credit history; motor vehicle history; criminal history; military service; and professional credentials and licenses.
FOR IDENTIFICATION PURPOSES ONLY
I understand and agree that my employer, Fairfield Hospital District, DBA Freestone Medical Center (the Company), has offered me conditional employment as a PRN employee subject to successfully passing a background check and drug screen.
Payment of Pre-Employment Background Check and Drug Screen for PRN Employees
- I understand that I am responsible for the full cost of my pre-employment background check and drug screen and authorize the Company to deduct the cost of these tests from my initial paycheck(s) up to $100.00.
- I understand and agree that I will be fully reimbursed for these costs if I am available and report to work for a minimum of 2 shifts per month over a 3- month period starting with my first assignment.
- I understand and agree that if I do not meet the requirements of #2 above, I will forfeit any and all reimbursements for these costs.
I understand the terms of this agreement and agree that the Company may deduct money from my pay as stated above. I further understand that the Company has stated its intention to abide by all applicable federal and Texas wage and hour laws and, that if I believe that any such law has not been followed, I have the right to file a wage claim with appropriate Texas and federal agencies.