Senior Director Chief Nursing Officer

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Other than minor traffic offenses, have you ever been, 1) convicted of a crime (misdeameanor or felony), 2) received a probated sentence (including deferred adjudication/pretrial diversion) for an alleged crime, 3) been assigned a probation officer, or 4) pleaded nolo-contendere to an alleged crime? ( A “Yes” response will not necessarily disqualify an applicant from employment.)

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Employment Acknowledgment

Important Read Carefully

1. I understand that my application will be considered active for 90 days (3 months) from date of completion and that a completed application does not constitute an employment agreement. If not hired during this period of time, I may complete another application.

2. I understand that this application and any attachments are the property of Driscoll Children’s Hospital.

3. If employed, I agree to be bound by the rules and policies of the hospital as made known to me at the time of employment or at any subsequent time; I further understand that I will be on an introductory period for ninety (90) days.

4. I understand, if offered employment, that as a condition of employment and as a condition of continued employment I am required to submit to and pass physical examinations and/or laboratory tests, or other tests that may be prescribed by the hospital.

5. I understand that I may be required to work varying hours including days, evening, nights, weekends, and holidays as patient care staffing needs of the hospital necessitate.

6. I certify that the statements made by me in this application and any attachment or documents, such as resumes, etc. submitted by me are true, complete and correct to the best of my knowledge and belief and are made in good faith.

7. I understand that any false statement, misrepresentation or omission of fact shall be sufficient cause for rejection of the application, or for the dismissal if such false statement is discovered subsequent to my employment.

8. I hereby authorize the authorities of the hospital to investigate all statements made on this application and release said hospital from any/all liability resulting from such investigation. I understand that Public Law 91-508 requires that the hospital advise me that routine inquiry may be made which will provide information concerning character, reputation, personal characteristics and mode of living. If such inquiry is made, I under­stand that I may obtain information as to the nature and scope of the report upon written request to the hospital.

9. I understand that if employed, my employment will be at will and may be terminated by the hospital or myself at anytime with or without cause. No hospital representative other than its president or a vice-president (and then only in writing) has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing.

10. I authorize DCH and its agents to confirm all information provided on this application, exhibits and resumes and to investigate my suitability for employment, including my work skills, work habits, ability, personal character and reputation. I agree to furnish additional information if requested. I release DCH and all persons and companies from any claims, liabilities or damages from obtaining or furnishing information about me. I under­stand that I will be provided a supplemental notification and authorization if DCH elects to conduct a consumer report about me under the fair credit reporting act.


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I agree with the Employment Acknowledgement above and I certify that all of the information in this application is true and correct as of this date.

Application Review