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Application For Employment

Equal opportunity employer

Norwood Medical is an equal opportunity employer and affords equal opportunity to all applicants for all positions without regard to race, color, religion, gender, national origin, age, disability, veteran status or any other status protected under local, state or federal laws.

Note: working required overtime is a condition of continued employment with Norwood Medical.

Section I: Applicant Information

If selected for an interview, you will need to provide your Social Security number at that time.

Please enter date in the following format: mm/dd/yyyy

Please enter date in the following format: mm/dd/yyyy

Section II: Position Interest

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Section III: Education and Training Information
Section IV: Work Experience And Previous Position
Please check each box that applies to your work experience
Previous Positions

List below your last three positions starting with the most recent

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Please enter date in the following format: mm/dd/yyyy

Please enter date in the following format: mm/dd/yyyy

Please enter date in the following format: mm/dd/yyyy

Please enter date in the following format: mm/dd/yyyy

Please enter date in the following format: mm/dd/yyyy

Section V: Reference

Please list below the names of three persons not related to you, whom you have known at least one year 

Section VI: Required Signature

**PLEASE READ CAREFULLY BEFORE SIGNING**

AUTHORIZATION

I certify that all of the information I have provided in this application and/or accompanying documents is true and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in this document will be cause for denial of employment or immediate termination of employment at any time.

I understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, unless it is in writing and signed by the board of directors. I also understand that all employees are employed at will, and may be discharged at any time for any reason. Nothing in the employee handbook, policy or hiring documentation is intended to create any legal rights in employees, expressed or implied.

I understand that if offered a position with Norwood Medical, I will be required to submit to a pre‐employment drug screening and background check as a condition of employment. I understand that unsatisfactory result from, refusal to cooperate with, or any attempt to affect the results of these pre‐employment tests and checks will result in the withdrawal of any employment offer or termination of employment if already employed.

I agree that any claim or lawsuit relating to my service with Norwood Medical, or any of its subsidiaries, must be filed no more than six months after the date of the employment action that is the subject of the claim or lawsuit. I waive any statute of limitations to the contrary.

REFERENCE CONSENT

I authorize the investigation of all statements contained in this application and any accompanying documents. I authorize Norwood Medical to obtain references from the employers I have listed above and on accompanying documents. I understand that information obtained will relate to my previous employment and any pertinent information they may have, personal or otherwise. I release Norwood Medical from all liability for any damage that may result from the utilization of such information. I agree to complete any necessary consent forms.

BACKGROUND CHECK CONSENT

I consent to undergo a pre‐employment background check as a condition of employment with Norwood Medical. The report will contain information regarding my felony and misdemeanor records. Additional information may be obtained regarding my education, credit standing, motor vehicle verification, etc. I agree to complete any necessary consent forms.

CONSENT TO DRUG/ALCOHOL TESTING

I consent to undergo pre‐employment drug and/or alcohol testing as a condition of employment at Norwood Medical. I consent to undergo drug and/or alcohol testing at any time during my employment upon the request of Norwood Medical. I understand that in the event I am injured while in the employment of Norwood Medical, I will be required to undergo drug and/or alcohol testing at the time medical attention is given, and I authorize the release of the test results to Norwood Medical without further notice or consent by me. I release Norwood Medical and the medical providers from all claims arising out of the testing and release of the information. I understand that my refusal to undergo drug and/or alcohol testing will result in my immediate termination.

By signing this form in the space provided below, I acknowledge that I have read, understand and consent to the terms and conditions outlined above.

THIS APPLICATION IS PART OF YOUR OFFICIAL EMPLOYMENT RECORD.

If selected for an interview, you will need to provide your Signature at that time.

If selected for an interview, you will need to provide the date at that time.