Guam Regional Medical City Employment Application Form (Page 4 of 4) in pdf

EMPLOYMENT APPLICATION

REFERENCES

PLEASE LIST TWO PROFESSIONAL REFERENCES AND ONE PERSONAL REFERENCE. DO NOT LIST RELATIVES AS REFERENCES

NAME

TITLE

ADDRESS

PHONE NUMBER

E-MAIL ADDRESS

DISCLOSURE / ACKNOWLEDGEMENT / AGREEMENT

HAVE YOU EVER BEEN CONVICTED OF A FELONY?

YES

HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR THAT RESULTED IN IMPRISONMENT?

YES

HAS YOUR PROFESSIONAL LICENSE IN ANY JURISDICTION EVER BEEN DENIED, RESTRICTED, SUSPENDED, OR

REVOKED? IF YES, PLEASE GIVE DATES AND EXPLANATION:

YES

I HEREBY CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

I FURTHER CERTIFY THAT I, THE UNDERSIGNED APPLICANT, HAVE PERSONALLY COMPLETED THIS APPLICATION. I UNDERSTAND THAT ANY

MISREPRESENTATION, FALSIFICATION OR OMISSION OF INFORMATION ON THIS APPLICATION OR ANY DOCUMENT USED TO SECURE

EMPLOYMENT SHALL BE GROUNDS FOR REJECTION OF THIS APPLICATION OR IMMEDIATE DISCHARGE IF AM EMPLOYED; REGARDLESS OF THE

TIME ELAPSED BEFORE DISCOVERY

I HEREBY AUTHORIZE GUAM REGIONAL MEDICAL CITY (GRMC) TO THOROUGHLY INVESTIGATE THE INFORMATION ON MY APPLICATION, MY

REFERENCES, WORK RECORD, EDUCATION AND OTHER MATTERS RELATED TO MY SUITABILITY FOR EMPLOYMENT AND, FURTHER AUTHORIZE

THE REFERENCES THAT I HAVE LISTED TO DISCLOSE TO GRMC ALL LETTERS, REPORTS, AND OTHER INFORMATION RELATED TO MY WORK

RECORDS, WITHOUT GIVING ME PRIOR NOTICE OF SUCH DISCLOSURE. I HEREBY RELEASE GRMC, MY FORMER EMPLOYERS AND ALL OTHER

PERSONS OR ENTITIES FROM ANY AND ALL CLAIMS, DEMANDS OR LIABILITIES ARISING OUT OF OR IN ANY WAY RELATED TO SUCH

INVESTIGATION OR DISCLOSURES.

I UNDERSTAND THAT IF CONSIDERED FOR EMPLOYMENT, I MAY BE REQUIRED TO: PROVIDE PROOF OF AUTHORIZATION TO WORK IN THE

UNITED STATES LEGALLY, PROVIDE PROOF OF HEALTH STATUS, COMPLY WITH GRMC’S PRE-EMPLOYMENT ACTIVITIES THAT INCLUDE

CONSUMER, CRIMINAL BACKGROUND, AND DRUG SCREEN, TO SIGN A CONFLICT OF INTEREST AGREEMENT AND ABIDE BY ALL TERMS OF

EMPLOYMENT.

I UNDERSTAND AND AGREE TO THE INFORMATION SHOWN ABOVE.

APPLICANT NAME (PRINT)

APPLICANT SIGNATURE

DATE SIGNED

Page 4 of 4

Guam Regional Medical City Employment Application Form Page 4