The Physicians' Hospital in Anadarko

Upload Resume

Step 1 of 3

Applicant*

First

Last
Phone*
Email*

Enter Email

Confirm Email
File
Max. file size: 8 MB.
CONTINUE TO NEXT PAGE FOR THE FIRST PHYSICIANS BACKGROUND INQUIRY AUTHORIZATION RELEASE

I understand that, as a condition of my consideration for employment with The Physicians Hospital in Anadarko (“TPHA”), or as a condition of my continued employment with TPHA, TPHA may obtain a consumer report that includes, but is not limited to, my creditworthiness or similar characteristics, employment and education verifications, social security verification, criminal and civil history, personal interviews, DMV records, any other public records and any other information bearing on my credit standing, credit capacity, character, general reputation, personal characteristics and trustworthiness. I hereby authorize and consent to TPHA’s procurement of such a report. I understand that, pursuant to the federal Fair Credit Reporting Act, TPHA will provide me with a copy of any such report if the information contained in such report is, in any way, to be used in making a decision regarding my fitness for employment with TPHA. I further understand that such report will be made available to me prior to any such decision being made, along with the name and address of the reporting agency that produced the report. The following is my complete and legal name, and all information is true and correct to the best of my knowledge. By signing below I consent to the procurement of a consumer report in connection with my application for employment.
Signature
Date*

MM slash DD slash YYYY
Name*

First

Middle

Last
ALTERNATE NAMES

Click on (+) button to add more rows.
Current Address*

Street Address

City

State

ZIP Code
PROFESSIONAL LICENSURE VERIFICATION

Type

LICENSE NUMBER:

State
PREVIOUS ADDRESSES

ADDRESS CITY/STATE ZIP DATES (MO & YR)

Click on (+) button to add more rows.
CONTINUE TO NEXT PAGE FOR THE FIRST PHYSICIANS DRUG TEST CONSENT FORM

CONSENT FOR PRE-EMPLOYMENT, RANDOM, OR REASONABLE SUSPICION DRUG TEST SCREEN AND RELEASE COVENANT NOT TO SUE AND INDEMNITY AGREEMENT I hereby CONSENT to allow The Physicians Hospital in Anadarko to take a specimen of my hair, urine, or blood and submit it for a pre-employment, random, or reasonable suspicion drug test screen. I FURTHER CONSENT to allow the laboratory testing service to make the results of such screen available to the prospective or current employer, The Physicians Hospital in Anadarko.In consideration for such services being rendered on my behalf, I hereby RELEASE the laboratory testing service, its officers, agents, and employees, from any and all claims which I might otherwise have due to such results being made so available. I hereby CONSENT NOT TO FILE ANY ACTION at law or in equity against The Physicians Hospital in Anadarko, the laboratory testing service, their respective officers, agents or employees in connection with the results of such screen being made so available, and I hereby agree to INDEMNIFY and SAVE HARMLESS The Physicians Hospital in Anadarko, the laboratory testing service, their respective officers, agents, and employees from all damages, expenses, reasonable attorney's fees, and costs of court which they or any of them may suffer or incur, jointly or severally, due to the results of such screen being made so available.
Signature*
Name*

First

Last
SIGNED this ___________day of _____________, 20___.*

ADDRESS	CITY/STATE	ZIP	DATES (MO & YR)

Submit Your Resume

Upload Resume

Step 1 of 3

CONTINUE TO NEXT PAGE FOR THE FIRST PHYSICIANS BACKGROUND INQUIRY AUTHORIZATION RELEASE

CONTINUE TO NEXT PAGE FOR THE FIRST PHYSICIANS DRUG TEST CONSENT FORM