Non-Discrimination Statement
Memorial Medical Center complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Memorial Medical Center does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Memorial Medical Center: •Provides free aids and services to people with disabilities to communicate effectively with us, such as: - Qualified sign language interpreters -Written information in other formats (large print, audio, accessible electronic formats, other formats) -Provides free language services to people whose primary language is not English, such as: -Qualified interpreters -Information written in other languages If you need these services, contact the Compliance Hotline at 715-685-5514. If you believe that Memorial Medical Center has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Jennifer Johnson, 1615 Maple Lane, Ashland, WI 54806, 715-685-5516, jljohnson@ashlandmmc.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Jennifer Johnson, Compliance Officer is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
Authorization and Release
I hereby authorize investigation of all statements contained in this application and agree that if any misrepresentation has been made by me herein or the results of an investigation are not satisfactory for any reason any offer of employment made to me by the hospital may be terminated immediately without any obligation or liability to me other than for payment, at the rate agreed upon, for services actually rendered if I have been employed.
In connection with my application for employment, I authorize the hospital and any agent acting on its behalf, to conduct an inquiry as to my personal history including and or all of my former employers, references, any agency and any or all educational institutions. I hereby release this hospital, and any agent acting on its behalf, from any and all liability of whatsoever nature by reason of requesting such information from any person.
If offered employment, I consent to a pre-employment physical examination and other health requirements including a drug test. If hired at MMC, I agree to future examinations as the hospital may require. I understand that an offer of employment and continued employment is contingent upon the satisfactory completion of employee health requirements.
Further, I also understand that any offer of employment is contingent upon the satisfactory completion of a criminal background check.
I hereby acknowledge that I have read and understand the foregoing.
