I hereby certify that the foregoing statements are to the best of my knowledge

I hereby certify that the foregoing statements are to

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any misstatements or omissions of material facts will constitute grounds for denial of or dismissal from employment. I hereby acknowledge that I am willing to work the scheduled shifts pursuant to the employee handbook. I further understand that my SUCCESSFUL COMPLETION OF A POST-OFFERPHYSICAL EXAMINATION WHICH WILL INCLUDE A TEST FOR SUBSTANCE ABUSE, AND RECEIPT OF VALID DOCUMENTATION VERIFYING MY ELIGIBILITY FOR EMPLOYMENT. In consideration of my employment, I agree to conform to all local, state, and federal lows, and to the rules, regulations, policies and procedures of Coal County General Hospital, Inc. and/or Coal County Extended Care, Inc. In addition, I understand andagree that any employee handbook, which I may receive, will not constitute an employment contract, but will be a general statement of Coal County General Hospital, Inc. and/or Coal County Extended Care, Inc. policies. I further understand that EMPLOYMENT IS AT WILL.You may contact my present employer? YesNo ___________________________________________________DateApplicant SignatureWE ARE AN EQUAL OPPORTUNITY EMPLOYERWord data disk/HR FORMS/Corporate ApplicationR/04/01/2014Employer NameAddressCityStatePhone Number________________________ ___________________________ _____________ _____ ____________________Employment DatesEnding SalaryJob TitleName of SupervisorFrom_____to_____________________________________________________________________________Job Duties:_____________________________________________________________________________________________________________________________________________________________________________________________Reason For Leaving This Employer:_______________________________________________________________________Employer NameAddressCityStatePhone Number__________________________ ___________________________ _____________ _____ ____________________Employment DatesEnding SalaryJob TitleName of SupervisorFrom_____to_____________________________________________________________________________Job Duties:_____________________________________________________________________________________________________________________________________________________________________________________________Reason For Leaving This Employer:_______________________________________________________________________Employer NameAddressCityStatePhone Number__________________________ ___________________________ _____________ _____ ____________________Employment DatesEnding SalaryJob TitleName of SupervisorFrom_____to_____________________________________________________________________________Job Duties:_____________________________________________________________________________________________________________________________________________________________________________________________Reason For Leaving This Employer:_______________________________________________________________________NameOccupationPhone #AddressCitySTZip1. ___________________ _______________________________________________________ __________2. ___________________ _______________________________________________________ ___________
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RELEASE AND AUTHORIZATIONPage 1In connection with my Employment Application with Coal County General Hospital, Inc. and/or Coal County Extended Care Inc., or as a current employee of Coal County General Hospital, Inc. and/or Coal County Extended Care, Inc., I understand and acknowledge that prior to employment with an Coal County General Hospital and/or Coal County Extended Care is subject to the Long Term Care Security Act [63 O.S. 1-1945 et.Seq.], I consent to a check of state and/or national licensure, certification, abuse, exclusion and offender registries, and fingerprinting for a state and national criminal history records check as required. Applicants with an active employment history in OK-SCREEN or previously fingerprinted for a license, certification or permit in Oklahoma where the authority having jurisdiction for the license, certification, or permit employs electronic criminal history monitoring, may not require fingerprinting.
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  • Fall '15
  • Tammy Eades
  • Coal County General Hospital, Coal County Extended Care

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