Physician Provider – Family Medicine - CHC/056

I certify that answers/information given herein are true, complete and accurate. I understand that any omission or misrepresentation of information may be sufficient cause for rejection of this application or, if employment has commenced, grounds for immediate dismissal. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I hereby authorize any schools that I have attended, current and previous employers, and organizations named in this application to provide the County of Will with any information that may be requested to make an employment decision. I hereby specifically waive written notice from any and all former employers regarding their disclosure to the County of Will of any information including disciplinary action. I understand that if I am offered employment, it is contingent upon satisfactorily passing a physical examination and/or drug test prior to placement in the position for which I have applied when such tests are required. I specifically authorize law enforcement agencies to release any records of prior criminal convictions and/or pending felony charges it may have or may obtain from other sources to the County of Will. I hereby release the County of Will and other agencies from any and all actions and claims that may be sustained by me from the release and use of the information. I understand and agree that in the absence of an express written agreement to the contrary executed by the employer, any employment I accept shall be for an indefinite term and shall be terminable at any time, with or without notice or cause, either by me or at the will and sole discretion of the employer. I have read or had read to me and understand the above statement. For purposes of this electronic form, my typed name in the signature box represents my signature. APPLICATIONS WITHOUT SIGNATURES WILL NOT BE CONSIDERED FOR EMPLOYMENT.