Decatur General

1201 7th Street SE

PO Box 2239

DecaturAL35609

Consumer Disclosure and Authorization for Background Investigation

I understand that this application is not an offer of employment and that by accepting my application Decatur General does not guarantee that I will be offered a job. I understand that if I am offered and accept a job, Decatur General reserves and retains the right to make such changes in the terms of my employment at any time as Decatur General determines,in its sole discretion,to be necessary or appropriate.

In consideration of my potential employment, I agree to conform to the rules of Decatur General, if hired. I understand and agree that any future employment is not for any guaranteed length of time, and that both Decatur General and I have the freedom to terminate the employment relationship whenever either chooses to do so.

I understand and agree that I will be required to successfully complete a pre-employment drug test and physical examination prior to beginning employment, but after conditional offer of employment has been extended.

I understand and agree that this employment application, policies, benefit plans, and any other hospital documents are not intended and should not be construed as a contract of employment, neither expressed nor implied.

I understand and agree that, if hired or given an unconditional offer of employment, any misrepresentations as to preexisting physical or mental conditions may void any Worker’s Compensation benefits.

I understand and acknowledge that it is the policy of Decatur General to provide equal opportunity to all individuals. In this regard, all personnel and administrative practices are administered without regard to race, religion, age, citizenship, sex, national origin, or physical or mental disability. This policy extends to patients, employees, and applicants for employment. I also understand that it is the policy of Decatur General to recognize the right of every employee to work in an environment free from any form of harassment and/or discrimination based on race, sex, religion, color, national origin, age, disability or any other factor prohibited by law. Suspected or possible violations of the policies may be reported to Administration, Human Resources, or any appropriate Department Head. I will comply with these and other policies of Decatur General and pledge to immediately report any violations of which I am aware.

I understand that, as part of its employment process, Decatur General may obtain information from a consumer reporting agency on applicants for employment and employees. By signing this document, I hereby expressly authorize Decatur General to obtain information regarding my creditworthiness, standing of capacity, character, background, general reputation, personal characteristics and/or mode of living. I understand that such information may be used by Decatur General in making decisions regarding my employment. Before DecaturGeneral takes any action adverse to me as an applicant or employee on the basis of a consumer report, I will be entitled to a free copy of that report, as well as a written description of my rights under the Fair Credit Reporting Act.

The consumer report/background investigation may contain the following types of information: verification of prior employment and dates of employment, academic achievement, professional licensure, and credit reports. I further understand the report may contain information about any prior criminal history, civil litigation, social security number verification, driving records, Uniform Commercial Code (UCC) filings, any liens or judgments, and bankruptcy as a result of public records search from any federal, state or any other agency which might contain such records.

All background information obtained shall be utilized to assist in verification of the employment application. Retrieval and usage of this information complies with all Equal Opportunity Commission, Americans with Disabilities Act and the Fair Credit Reporting Act (laws, rules and regulations). Decatur General is an Equal Opportunity Employer and does not discriminate as to race, color, gender, national or religious origin, age, disabilities or any other characteristic protected by law.

Social Security # Driver Licenses #

Signature of Applicant Date

I authorize Decatur General to obtain information concerning my prior employment

Signature of Applicant Date

I do not authorize Decatur General permission to obtain information concerning my prior employment

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Signature of Applicant Date