APEX HOSPITAL - HOUSTON

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Application for Employment

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

INSTRUCTIONS:

Complete all the necessary information. You may be asked to provide additional information
on another form. This application will be kept on file, it is to your advantage to periodically check to keep it current and active. Be sure to sign and date the application.

(PLEASE PRINT)

As an Equal Opportunity / Affirmative Action Employer, APEX Hospital L.P. and its affiliates, does not discriminate against applicants or employees because of their age, race, color, religion, national origin, sex, disability or on any other basis prohibited by law including but not limited to disabled veteran and/or veteran of the Vietnam are

For Internal Use Only
No Opening in Job Classification Applicant took other job Unable to contact	Applicant rejected offer Found Unqualified Hired

PERSONAL INFORMATION
Date			Social Security Number
Name (Last)		(Middle)	(First)
Current Address			Phone Number ( )
City	State	ZIP Code	Country
Email

WORK AUTHORIZATION

Are you legally authorized to work in the USA? Yes No

TO COMPLY WITH THE IMMIGRATION REFORM AND CONTROL ACT, IF YOU ARE HIRED, YOU WILL BE REQUIRED TO PROVIDE DOCUMENTS TO ESTABLISH YOUR IDENTITY AND YOUR AUTHORIZATION TO WORK IN THE USA. SUCH DOCUMENTS WILL BE REQUIRED WITHIN THE FIRST THREE (3) BUSINESS DAYS FOLLOWING YOUR HIRE, OR UPON YOUR FIRST WORK DAY IF YOUR EMPLOYMENT WILL BE LESS THAN THREE (3) DAYS.

RECORD OF EDUCATION

Name and Address of School(s)

Dates Attended

Graduated

Type of
Degree/Diploma
Received or
Expected

Major /
Minor
Fields of
Study

From
Optional

To
Optional

Yes

High School (last attended)
Colleges & Universities
Graduate School
Other: Business Technical Secretarial Etc...

PLEASE LIST ANY PROFESSIONAL AFFILIATIONS OR ACCREDITATIONS THAT HAVE A DIRECT
BEARING UPON YOUR QUALIFICATIONS FOR THE JOB FOR WHICH YOU ARE APPLYING.

INCLUDE ALL LICENSES AND CERTIFICATIONS:

HAVE YOU EVER HAD YOUR PROFESSIONAL LICENSE OR CERTIFICATION SUSPENDED, REVOKED,
OR RESTRICTED?

Yes No

IF YES, PLEASE EXPLAIN:

DO YOU HAVE ANY SPECIAL SKILLS OR ABILITIES THAT DIRECTLY RELATE TO THE JOB FOR
WHICH YOU ARE APPLYING?

PLEASE LIST:

WORK EXPERIENCE
(List Most Recent Experience First)

Employer Name

FROM: (Employment Start Date)

TO: (Employment End Date)

Starting Position

Ending Position

Address

Supervisor Name & Title

City, State ZIP

Beginning
Salary/Wage

Ending
Salary/Wage

Reason for Leaving:

Phone

Eligible for Rehire?
Yes No

MAY WE CONTACT YOUR CURRENT EMPLOYER LISTED ABOVE? Yes No

Employer Name

FROM: (Employment Start Date)

TO: (Employment End Date)

Starting Position

Ending Position

Address

Supervisor Name & Title

City, State ZIP

Beginning
Salary/Wage

Ending
Salary/Wage

City, State ZIP

Phone

MAY WE CONTACT YOUR CURRENT EMPLOYER LISTED ABOVE? Yes No

Employer Name

FROM: (Employment Start Date)

TO: (Employment End Date)

Starting
Position

Ending
Position

Address

Supervisor Name & Title

City, State ZIP

Beginning
Salary/Wage

Ending
Salary/Wage

City, State ZIP

Phone

MAY WE CONTACT YOUR CURRENT EMPLOYER LISTED ABOVE? Yes No

Use this space to describe any previous work history and/or detail particular job responsibilities listed above that you believe are important or should be considered. Include any additional information you feel may be relevant to the job for which you are applying.

This application shall only remain active for 60 days. After 60 days, if you are still interested in employment at this Company, you must fill-out a new application.

I hereby do certify that all statements made in this application are true and correct to the best of my knowledge and belief. I understand and agree that any misrepresentation or omission of facts in my application may be justification for refusal to hire or termination of employment.

I give the Employer the right to investigate all references, to contact all prior employers and to secure additional information about me, if job related. I hereby release from liability the Employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. I agree to immediately notify the Company if I am convicted of, receive deferred adjudication in, or otherwise plead guilty or no contest to a felony or any crime involving dishonesty, breach of trust or injury to a person, while my application is pending or during my employment if hired.

REFERENCES (Name, City, State) Phone Number Reference Type:

1.	( )	Personal Business
2.	( )	Personal Business
3.	( )	Personal Business
4.	( )	Personal Business

I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contact between this Company and me for either employment or for the providing of any benefit. If I am offered and accept employment, I understand that the employment is for no definite period of time and may (regardless of the date and payment of my wages and/or salary) be terminated at any time, with or without cause. I understand that if this Company employs me, I will be employed as an employee at will.

I understand that, subject to Employers obligations under the Americans with Disability Act (ADA), I must meet all the physical standards established by this Company to perform the essential functions of any job for which I am offered employment. I understand that, if offered employment, I might be required as a condition of employment to take a physical examination. I also understand that, subject to Employers requirements under the ADA, during employment I might from time to time be subjected to physical examinations and/or physical ability test to demonstrate that I can perform the essential functions of my job.

I understand that this Company requires that I take a drug test as a condition of pre-employment and may from time to time require that I take a drug and/or alcohol test as a condition of employment. This Company reserves the right to conduct searches on company property of employees and their personal property for alcohol, drugs, or for property which might belong to this Company. This Company also reserves the right to conduct searches of the companys property, vehicles and/or equipment at any time. A refusal to submit to a company search can subject an employee to employment termination.

This Company is an equal opportunity employer. This Company does not discriminate against applicants or employees because of their age, race, color, religion, national origin, sex, disability or on any other basis prohibited by law including but not limited to disabled veteran and/or veteran of the Vietnam era.

In signing this form, I certify that I understand and have truthfully answered all the questions and statements in this application.

Signature of Applicant Date

PLEASE RETURN THIS APPLICATION TO
HUMAN RESOURCE DEPARTMENT

AUTHORIZATION AND RELEASE FOR BACKGROUND CHECK

I, the undersigned consumer, do hereby authorize APEX Hospital L.P. by and through its independent contractor, to procure a consumer report and/or investigative consumer report on me.

These above-mentioned reports may include, but are not limited to, information as to my character, general reputation, personal characteristics, and mode of living, discerned through employment and education verifications; personal references; personal interviews; my personal credit history based on reports from any credit bureau, if applicable; my driving history, including any traffic citations; a Social Security number verification; present and former addresses; criminal and civil history/records; and any other public record.

I understand that I am entitled to a complete and accurate disclosure of the nature and scope of any investigative consumer report of which I am the subject upon my written request to APEX Hospital Human Resource Office, if such is made within a reasonable time after the date hereof.

I would like a copy of my background report:
Yes No

I authorize any person, business entity, or governmental agency who may have information relevant to the above to disclose the same to

APEX Hospital by and through its independent contractor, including, but not limited to any and all courts, public agencies, law enforcement agencies, and credit bureaus, regardless of whether such person, business entity, or governmental agency compiled the information itself or received it from other sources.

I hereby release APEX Hospital, its independent contactor, and any and all persons, business entities and governmental agencies, whether public or private, from any and all liability, claims, and/or demands, by me, my heirs, or others making such claim or demand on my behalf, for providing a consumer report and/or investigative consumer report hereby authorized. I understand that this Notice/Authorization and Release form shall remain in effect for the duration of my employment with APEX Hospital.

I give APEX Hospital permission to investigate any incidents of workplace misconduct of which I have been accused for which I am alleged to have been involved during employment with APEX Hospital.

I certify that the information contained on this Notice/Authorization and Release form is true and correct and that my application or employment may be terminated based on any false, omitted, or fraudulent information.

PERSONAL INFORMATION

Date

Social Security Number

Date of Birth
(used only to avoid isidentification)

Gender
Male Female

Name (Last) (First) (Middle)

Current Address

Phone Number
( )

City

State

ZIP

Country

ADDRESSES FOR THE PAST SEVEN (7) YEARS

City

State

ZIP

County

Dates Lived Here

From:

To:

From:

To:

From:

To:

PROFESSIONAL LICENSURE AND/OR CERTIFICATIONS

Current and Previous Professional Licenses or Certifications

License/Certification #

State Issued

Expiration Date

Drivers License Number

State

If you answer yes to any of the questions below, please explain on a separate piece of paper. A conviction, pending charge, or deferred judgment will not necessarily disqualify you from employment. Each conviction, pending charge, or deferred judgment will be evaluated on its own merits with respect to time, circumstances, and seriousness in relation to the job applied for. In addition, certain state laws may bar your employment.

Have you ever been convicted of or plead guilty or no contest to a crime (felony or misdemeanor) other than a minor traffic violation? If so, please explain. For purposes of employment with this Company, convictions include sentenced to confinement, paid fine, time served, placed on probation (including deferred adjudication) and court-ordered restitution. Yes No

Is there a pending criminal charge against you or are you currently under investigation? Yes No

Is there a deferred criminal judgment against you?
Yes No

Have you ever been sanctioned, disciplined, debarred and/or excluded by a duly authorized regulatory agency, or are there any current restrictions or limits on your license(s) or certification(s)? Yes No

Signature Date :

SUBSTANCE ABUSE AND TESTING POLICY
ACKNOWLEDGEMENT AND CONSENT

I. AGREE TO BE BOUND BY POLICY
I do hereby agree to be bound by APEX Hospital, L.P. (the Company) Substance Abuse and Testing Policy (the Policy), the terms of which are incorporated here in by reference, as a condition for employment and for purposes of applying for, accepting, or continuing employment with APEX Hospital, L.P..

II. DRUG FREE STATEMENT
I also hereby state that I am not a user of controlled substances, which have not been prescribed for me by a licensed physician for authorized use. I agree to comply with the Drug-Free Workplace Act provisions under the Companys Substance Abuse and Testing Policy and understand that, as a condition of employment, I must notify the Company if I am convicted of a criminal drug offense occurring in and/or outside the workplace no later than five (5) days after any such conviction.

III. HOLD HARMLESS PROVISION
I hereby agree to furnish a specimen, as required or requested, for testing under the Policy. I also agree that any Company employee who has been authorized and designated by the company for such purposes, or any physician, laboratory, hospital, or medical professional that has been authorized and designated by the Company for such purposes, may perform appropriate chemical tests on my specimen for the presence of illegal drugs or prescription drugs for which I do not have a valid prescription. I further acknowledge that my application for employment or my continued employment with the Company may be affected consistent with the terms of the Policy based upon a positive result of any such test showing substance usage in violation of the Policy.

To the full extent authorized by applicable laws, rules, and regulations, I release and hold the Company, any such designated person or institution identified above, any laboratory utilized under the Policy, their respective employees, agents, and other contractors for services under the Policy, harmless from any liability (including any liability arising by virtue of negligence) arising from any request made to furnish any required specimen for testing, the testing of such specimen pursuant to the Policy, the release of information in accordance with this authorization and any decisions made concerning my application for employment or my continued employment with the Company based upon a positive result of such test showing drug usage in violation of the Policy.

IV. CONSENT TO THE RELEASE OF TEST RESULTS
I hereby give my permission to any Company employee who has been authorized and designated by the Company for such purposes, and any physician, laboratory, hospital or medical professional that has been authorized and designated by the Company for such purposes, to release the results of any tests made pursuant to the Policy to the Company, the Companys designated Medical Review officer, the Companys Workers Compensation insurance carrier, and any other person who has a lawful right or need to be informed of such results.

In the event I am seriously injured in a work related accident and unable to provide a specimen at that time, I do hereby authorize the Company to obtain, and the treating facility to release, any hospital reports, other documents or specimens which would indicate whether or not there were any controlled substances or alcohol in my system at the time of the accident.

The undersigned further states that he or she has read the provisions of the policy and the foregoing acknowledgement and consent form, or had such documents read to him or her, knows the content thereof and has freely and voluntarily affixed his or her signature on this document.

I hereby freely and voluntarily agree to the terms of this Substance Abuse Policy Acknowledgment and Consent Form.

This Hospital performs:

Pre-Employment Drug Testing

Post-Employment Drug Testing

Random Drug Testing

Upon Observed Behavior Drug Testing

The above are the primary reasons for drug testing, but we reserve the right to test for other justified reasons.

Applicant / Employee Name (Please Print Name)

Social Security Number

Applicant / Employee Signature

Date

Witness Signature

Date