Please read carefully. Omission of information except as noted, will invalidate your application from consideration.
I hereby authorize Signature Ambulance to receive and share any criminal history record information, with perspective employers pertaining to me which may be in the files of any state or local criminal justice agency in Georgia.
I hereby state that the information given by me in my employment application is true and complete in all respects. I understand that in consideration of my application, an investigation may be conducted of my past employment and activities. I authorize past employers, personal references and any other persons with whom I am acquainted to answer all questions asked converning my previous employment record, ability, military service, education background, medical history, criminal record history, credit history, driving record, workers' compensation claims, character and reputation. I release all persons, including past employers, credit bureaus and government agencies, from any liabilities or damages on account of having furnished such information in good faith.
In consideration of my application, I authorize Signature Ambulance, and/or its agents to conduct such an investigation and release Signature Ambulance, including its agents, officers, employees and representatives from all liability or responsibility for this investigation. I understand that the information requested below regarding sex, race and date of birth are for the sole purpose of gathering the above information accurately and will not be used to discriminate agaist me in violation of any law. I understand any initial employment offer will be contingent until all information is obtained and processed, including results of a urine drug test, and may be subsequently withdrawn based on the results of these investigations.
I understand that a consumer report may be requested or an investigation conducted. I further understand that if employment is denied in whole or in part because of information obtained from a consumer reporting agency, I have the right to make a written request within a reasonable period of time to receive information about the scope and nature of the investigation. A fax or a photo copy of this authorization shall be valid as the original.
Signature Ambulance is committed to maintaining a safe, productive work environment at all facilities and work sites and to safeguarding all property connected with such employment. Because the concern for the safety of all Signature Ambulance associates is paramount, the signing of the Drug and Alcohol Testing Consent Form, constituting agreement and cooperation with this policy, is required of all persons as a condition of employment by Signature Ambulance.
It is the policy of Signature Ambulance not to retain any individuals who test positive for any illegal drug in their system or use illegal drugs or controlled substances, in any amount, regardless of frequency, without a medically acceptable prescription. Therefore, to rule out the presence of non-prescribed or prohibited dangerous substances in the body, Signature Ambulance associates may, consistent with state law, be required to undergo a drug screening test for any or all of the following reasons:
In addition, Signature Ambulance associates may be required to undergo alcohol screening when there is suspicioun of impairment or a critical event (work-related injury, unusual behavior, etc.).
I understand that according to signature Ambulance policy, I may be required to sibmit a sample of my urine and/or other body fluids, tissue or filaments for chemical analysis. I understand that qualified personnel will perform the analysis.
I consent freely and voluntarily to this request for a specimen of urine and/or other body fluids, tissues or filaments. I hereby and herewith release Signature Ambulance, the medical provider obtaining the samples and the laboratory performing the analysis (including its employees, agents and contractors) are not liable whatsoever arising from this request to furnish my urine and/or other body fluids, tissues or filaments, the testing of the sample and decision made concerning my employment based upon the results of the analysis.
I understand that any person refusing to take or failing to pass the drug-screening test will not be qualified for employment with Signature Ambulance until a negative drug test result can be obtained. Initial testing and confirming tests for positive results are at the expense of Signature Ambulance. Retesting is at my expense, consistent with state law.
I have read the foregoing policy statement and consent form and understand and agree to submit to drug and alcohol testing as part of the terms and conditions of my employment with Signature Ambulance.
9 Allen Cail Dr.Statesboro, GA 30458