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 Complete the form below to express your interest in employment with Lawrence County Memorial Hospital.
Personal Information
Are you at least 18:
Are you willing to take the required Drug Tests?:
Have you been employed here before?:
Do you have a valid drivers license?:
Have you ever been debarred or excluded from participation in Medicare, Medicaid or any other federal or state funded health care program?:
Employment History
Professional References
Do not list relatives

This institution is an Equal Opportunity Employer and does not discriminate in hiring or any other decision on the basis of age, race, color, religion, national origin, citizenship status, unfavorable discharge from the military, marital status, disability or gender. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination, and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination, drug screen and background check.

If employed, I understand that I will be required to comply with the rules and regulations of all federal, state and local governments.

I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (I-9), and within three days, show satisfactory evidence of identity and eligibility for employment.

I certify that I have read, fully understand and accept all terms of this Applicant Statement and Release.:
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