I have disclosed all information that is relevant and should be considered applicable to my candidacy for employment.

I hereby give you my permission to contact the above employers, references, and educational, licensing, credentialing and certification institutions to verify the items I listed above. I hereby release Hope Network and the above referenced organizations, reference persons and employers from all claims, liability and damages that may result from furnishing the information to you. I consent to releasing any information relating to my job performance which is documented in my personnel file. In the event that a prior employer or other organization is obligated to provide any written notice to me regarding the disclosure of information to Hope Network. I hereby waive that obligation and expect no written notice of disclosure of my personal information.

I understand as a part of the credentialing process I may need to establish a National Practitioner Identifier (also known as NPI number). I hereby agree to accept connection with Hope Network and affiliates through the Identity and Access System to allow the organization to manage my National Plan & Provider Enumeration System record (NPPES).

I also understand that because of the nature of my job and licensing requirements, I hereby consent to the release of this application or portions of this application to representatives of the Department of Human Services, Department of Community Health, local community mental health entities or other governmental agencies or private agencies, for all licensing or investigatory purposes and to verity information I have listed in this job application. I hereby release Hope Network., State of Michigan, Department of Human Services, Department of Community Health, local community mental health entities and other governmental agencies or private agencies from all claims, liability, and damages that may result from furnishing the information to you.

Any misrepresentation or falsification of information/data may result in the individual no longer being considered for employment, or if employed, it may result in the termination of employment regardless of the time elapsed before the discovery.

I hereby release Hope Network from all claims, liability, and damages that may result from furnishing the information to you. I further specifically waive written notice and agree to the divulging of any disciplinary reports, letters of reprimand or other disciplinary action by all prior employers, and hereby release any prior employers from all claims, liability and damages that may result from furnishing the information to you.

I understand, where permissible under applicable state and local law, I may be subject to a pre-employment drug test after receiving a conditional offer of employment, and must receive a negative result for illegal drug use before being permitted to commence work with Hope Network.

I understand, where permissible under applicable state and local law, I may be subject to a pre-employment medical examination, which includes: physical, TB testing and finger printing (if applicable) after receiving a conditional offer of employment. These results must meet the qualifications for the position, with or without reasonable accommodation to work as a Hope Network employee.

I understand, where permissible under applicable state and local law, I may be subject to a pre-employment background check after receiving a conditional offer of employment to investigate my criminal background and other matters related to my suitability for employment. Also, I am aware that if offered employment, I may be subject to random drug and/or alcohol testing for cause at the employer’s discretion.

I understand employment with Hope Network is also contingent on my providing sufficient documentation necessary to establish my identity and eligibility to work in the United States.

If employed, I understand that as a condition of employment that I may be required to agree to and sign a non-solicitation, non-disclosure, and/or other similar agreements. I also agree to notify the organization during the pre-employment process of any non-solicitation, non-disclosure, and/or other similar agreements that I may have already signed with current and former employers.

I understand that the technical processing and transmission of the application, including my personal information, may involve (a) transmissions over various networks, including the transfer of this information to the United States and/or other countries for storage, processing and use by Hope Network, its affiliates, and their agents; and (b) changes to conform and adapt to technical requirements of connecting networks and devices. Accordingly, I agree to permit such parties to make such transmissions and changes, and hereby provide the necessary consent for the same.

I certify that all of the above information is true and complete, and I understand that any falsification or omission of information may disqualify me from further consideration for employment or, if hired, may result in termination regardless of the time elapsed before discovery.

I hereby release the employer and agents an all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the request for or release of any of the above mentioned information or reports.

I AGREE, AND IT IS MY INTENT, TO SIGN THIS EMPLOYMENT APPLICATION BY CHECKING THE "I ACCEPT" BOX BELOW AND BY ELECTRONICALLY SUBMITTING THIS DOCUMENT TO COMPANY, I UNDERSTAND THAT MY SIGNING AND SUBMITTING THIS DOCUMENT IN THIS FASHION IS THE LEGAL EQUIVALENT OF HAVING PLACED MY HANDWRITTEN SIGNATURE ON THE SUBMITTED DOCUMENT.

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