STATEMENT OF UNDERSTANDING AND RELEASE

• I voluntarily give Franklin Medical Center the right to make a thorough investigation of my past employment and activities. I agree to cooperate in such an investigation. I authorize Franklin Medical Center to contact any third party who may have information on any matter reasonably bearing on my qualifications for this employment. I specifically authorize these third parties to release all requested information about me to Franklin Medical Center or its authorized representative. I hereby release from all liability or responsibility all persons, companies or corporations supplying or receiving such information. After employment, any doctor or hospital may release all information necessary for the Hospital to determine my abilities to perform specific job duties now or in the future. I consent to take the pre-employment physical examination and such physical examinations as may be required by this institution at such times and places as the institution shall designate.

• I understand that my employment will be terminated for any misstatement or omission of fact appearing in this application form.

• I further understand that this institution follows the “fair employment practice code” and there is no discrimination in hiring of or employment on the basis of sex, age, race, color, religion, creed, marital status, national origin, ancestry, disability, military or Vietnam Veteran Era Status, handicap unrelated to ability to perform the work required.

• In consideration of my employment by Franklin Medical Center, I agree to conform to the rules and policies of the Hospital. I understand that my employment and compensation can be terminated or changed, with or without cause, and without prior notice at any time, at the option of the Hospital. I understand that no manager or representative of Franklin Medical Center, other than the Administrator or Board of Commissioners, by written contract, has the authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing.

• I certify that I am not presently barred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation by any Federal department or agency.

• I authorize the release of reference information on my work. I further authorize payment of any obligations owed by me or members of my immediate family to Franklin Medical Center from the monies due to me from my employment.

• I authorize the hospital to conduct a pre-employment blood and/or urinalysis screening for drugs and/or alcohol.

• I understand that conditions may require me to work shifts or days other than the ones for which I am applying and I agree to scheduling changes (reassignment of duties or positions, overtime, shift work, rotating work schedules or any combination of a work schedule) as directed by my Department Manager or the Administrator of this institution.

• By submitting this form I agree that I have read and understand the above and hereby certify that the facts I have provided in my employment application are true and complete.