P E R S O N A L R E F E R E N C E S
(Do not list former employers or relatives)
Name
Occupation
Address
Telephone
I
II
R E F E R E N C E S F R O M F O R M E R C O - W O R K E R S
Name
Occupation
Address
Telephone
I
II
III
IV
A G R E E M E N T
It is the policy of ARNOT OGDEN MEDICAL CENTER, ELMIRA, NEW YORK, to provide equal opportunity without regard to race,
color, national origin, creed, sex, age, disability, marital status and other reasons prohibited by law. This policy applies to all areas of
employment including recruitment, placement, training, transfer, promotion, lay-offs, termination, pay and other forms of compensation
and benefits.
In signing this application, I affirm that to the best of my knowledge all statements on this application are true and complete without
omission of any kind. I understand any misrepresentation is sufficient cause for dismissal from employment or disqualification from
further consideration for employment. I understand and agree that if employed by Amot Ogden Medical Center or any of its subsidiar-
ies, my employment will be at will and without fixed term. I also understand that I may terminate my employment at any time provided I
give notice as required by hospital policy and procedure guidelines. Arnot Ogden Medical Center or its subsidiaries reserves the right
to terminate my employment at any time without prior notice.
I understand that my employment is dependent upon a thorough investigation of my records and references as well as successfully
passing a physical examination. I agree to abide by all ARNOT OGDEN Rules and Regulations.
DATE
SIGNATURE OF APPLICANT
A U T H O R I Z A T I O N F O R
R E L E A S E O F I N F O R M A T I O N
I, the undersigned, give Arnot Ogden Medical Center permission to verify my background and suitability for employment. I release from
any and all liability any individual, employer, educational institution, professional organization, etc. which may provide such informa-
tion. I also waive my right to inspect this reference information.
I request that my current employer not be contacted unless I am in the final stages of consideration for a position.
DATE
SIGNATURE OF APPLICANT
Please do not write below this line.
Interview:
Yes
No Date
__________
Interviewer
Time
Interview:
Yes
No Date
__________
Interviewer
Time
