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Answering yes to this question does not automatically exempt you from employment. The hiring committee will review the conviction(s) using the following factors: (1) the nature and gravity of the offense; (2) the amount of time that has passed; and (3) the nature of the job. The committee will consider whether such conviction relates to the specific position in question. You may include additional documentation/information if desired.
Availability Information
Education Information
Employment Information
List all previous work experience with most recent first. Explain any period of unemployment.
Employment Information 2/5
Employment Information 3/5
Employment Information 4/5
Employment Information 5/5
Persons we may contact to verify your qualifications for the position. (Do not list relatives or former employers.)
References 2/3
References 3/3

Agree & Certify

“I certify that information given by me in this application is true and complete in all respect, and that if any information given is found to be false or incomplete in any way, it shall be considered sufficient cause for denial of employment or discharge if discovered after being hired. I authorize the use of any information in this application to verify my statements, and I authorize all employers, all references, and any other persons to answer all questions asked concerning my ability, character, reputation, and previous employment record. I release all such persons from any liability or damages on account of having furnished such information.”

“I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Cookeville Regional Medical Center or any Affiliates and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Cookeville Regional Medical Center or its Affiliates unless made in writing. If an employment relationship is established, I understand that all employment is on an at-will basis, meaning I have the right to terminate my employment at any time with or without cause, and that Cookeville Regional Medical Center and Affiliates retains the same right.”

“If extended a conditional offer of employment, I agree to submit to a drug / alcohol screen and medical examination, and I understand my becoming employed will be conditional upon a negative drug / alcohol screen result and the results of a medical examination to verify my ability to perform the essential elements of the job in accordance with hospital policies and procedures.”

“I understand that if employed, policies and rules which are issued are not a contract, but do constitute conditions of my continued employment, and that Cookeville Regional Medical Center and its Affiliates may revise policies or procedures, in whole or in part, at any time. Further, I understand that any employment is not for a stated period of time and may be terminated with or without cause at any time at the option of either myself or my employer.”

“I understand that if employed I will be in an introduction period for three (3) months. During the trial period either party may terminate without notice. All obligations of the institution shall end with the last day I work.”

“I understand that Cookeville Regional Medical Center and its Affiliate campuses are Tobacco-free and all tobacco use will be prohibited.”

“I certify that I (a) am not currently excluded, debarred, or otherwise ineligible to participate in the Federal and/or State health care programs; (b) have not been convicted of a criminal offense related to the provision of health care items/services; and (c) I am not waiting to be excluded, debarred, or otherwise declared ineligible.”