By signing below, I certify that the answers and information set out above are true, accurate and complete to the best of my knowledge. I acknowledge that if any answer or information is not true, accurate or complete, I may not be hired, or if hired, I may be discharged. I authorize Burgess Health Center to investigate all statements contained in this application for employment and to investigate my character and qualifications. I authorize my prior employers, references, and others with information regarding my work or educational history or my character, to provide Burgess Health Center with all requested information and references, and to cooperate fully with the investigation of my character and qualifications.
I understand that this application is not a contract of employment. I also acknowledge that no oral representations have been made, and that no one within Burgess Health Center has the authority to make oral contracts of employment. If hired, my employment relationship with Burgess Health Center is terminable at-will, with or without cause, by either myself or Burgess Health Center.
I also understand that my employment will be conditioned upon a favorable criminal and abuse registries background check and health evaluation including drug screening, which may include a medical examination by a physician selected by this employer, to which I hereby consent.
I agree to notify Burgess Health Center in writing within five (5) days of receiving any written or oral notice of any adverse action, including, without limitation, exclusion from participation in any federal or state health care or procurement programs, any filed and served malpractice suit or arbitration action; any adverse action by Licensing Board taken or pending; any adverse action which has resulted in the filing of a report with the Licensing Board; any revocation of DEA license; a conviction of any felony or a misdemeanor of moral turpitude; any action against any certification under the Medicare or Medicaid programs; or any cancellation, non-renewal or material reduction in medical liability insurance policy coverage.
I understand and agree to all of the conditions and statements set forth above, and throughout this application.