MDS Coordinator

Please list your job history for the past ten years or the last three employers: starting with your present or most recent employment. Include military service. Do not include internships or explanations of periods of unemployment; include those in section "Additional information".

PLEASE READ CAREFULLY BEFORE SIGNING

Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, ancestry, sexual orientation, or the presence of a disability or handicap.

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application or any other pre-employment documents shall result in termination when discovered. I authorize you to obtain an investigative consumer report and/or a report from any law enforcement agency which may include both general and personal information about me if I am offered employment or at any time during my employment. I authorize investigation of all statements contained herein and authorize the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from all liability for any damage that may result from furnishing same to you.

In consideration of my employment, I agree to conform to the rules and regulations of the Company and agree that my employment and compensation can be terminated, with or without cause, and with or without notice, at any time, at the option of either the Company or myself and without notice or liability for wages or salary except such earned at the date of such termination. I understand that no manager, supervisor, or representative of management, other than the President (or ranking officer), has any authority to enter into an agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.

In the event that I am employed, I understand that regardless of the shift and job that I am first assigned, I may be required to accept a change of job or shift depending on my demonstrated skills after employment and the needs of the Company. I consent to take any physical or medical examinations, including blood and urine or other tests for alcohol and drugs, requested by the Company in connection with the processing of my application for employment and further agree to take any such physical or medical examinations requested by the Company during my employment if I am offered and accept a job. I understand that such an examination may be needed in order to determine my competence to perform the job or work for which I was hired, or to identify any physical or mental condition bearing on my job performance. I understand that refusal to submit to any physical or medical examination ordered by the Company will result in rejection for employment or for disciplinary action up to and including immediate discharge. I further understand that any information obtained through such exams may be retained by the Company and is exclusively the Company s property. I also understand that the examinations will be performed by medical personnel, clinics, or laboratories qualified to do the necessary work and costs for such examinations will be borne by the Company.