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(One Name Only)", "questionId": "PHP_DQ_010_dep", "required": true, "type": "text-row"}, {"label": "<div style=\"\"><div style=\"width:90%;text-align:justify;border:1px solid black; border-radius:1%;padding:1%\"><p style=\"text-align:center;text-decoration:underline;\"><b>STATE SPECIFIC APPLICATION ADDENDUM</b></p><p><b>California:</b> I understand the Company may obtain, without using the services of a third party inves-tigative consumer reporting agency, public records pertaining to my character, general reputation, personal characteristics or mode of living during its evaluation of my application for employment and, if employed, during my employment. By checking the following box, I waive my right to receive copies of public records obtained by the Company.</p><p><B>Maryland: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.</b></p><p><b>Michigan</b>: Persons with disabilities needing accommodations for employment must notify the Company in writing of the need for an accommodation within 182 days after the date the person with a disability knew or reasonably should have known that an accommodation was needed. We will endeavor to make a reasonable accommodation to the known limitations of a qualified applicant with a disability unless the accommodation would impose an undue hardship on the operation of our business. If you believe you require such assistance to complete this form or to participate in an interview, please check the following box.</p><p style=\"text-align:center;text-decoration:underline;\"><b>STATE SPECIFIC DISCLAIMERS</b></p><p><b>ARIZONA:</b> To the extent required by applicable law, the Company maintains a smoke-free workplace.</p><p><b>BOULDER, CO:</b> Premier Health is committed to maintaining a safe and efficient workplace and in promoting the health and welfare of patients, visitors, and employees. It is Premier Health\u2019s policy that all applicants are required to successfully complete a pre-employment drug screen upon receipt of a conditional offer of employment. A copy of Premier Health\u2019s drug free workplace policy will be provided to applicants prior to any pre-employment drug screening upon conditional offer.</p><p><b>CONNECTICUT:</b> Premier Health is committed to maintaining a safe and efficient workplace and in promoting the health and welfare of patients, visitors, and employees. All applicants are required to successfully complete a pre-employment drug test upon receipt of a conditional offer as a part of the pre-employment screening process.</p><p><b>MARYLAND:</b>  The Company considers this Application for Employment to be a part of the personnel record.</p><p><b>MASSACHUSETTS:</b> Note that it is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.</p><p><b>MINNESOTA:</b> Premier Health is committed to maintaining a safe and efficient workplace and in promoting the health and welfare of patients, visitors, and employees. It is Premier Health\u2019s policy that all applicants are required to successfully complete a pre-employment drug screen upon receipt of a conditional offer of employment. A copy of Premier Health\u2019s drug free workplace policy will be provided to applicants prior to any pre-employment drug screening upon conditional offer. Additionally, copies of Premier Health\u2019s drug free workplace policy are available for inspection by applicants during regular business hours.</p><p><b>RHODE ISLAND:</b> As of 02/2023, Premier Health is not currently subject to chapter 29-38 of Title 28 in Ohio.</p><p style=\"text-align:center;text-decoration:underline;\"><b>APPLICANT'S STATEMENT</b></p><p>I have read and fully understand the questions asked in this application.  I certify that all of the answers I have given are true, accurate and complete.  I understand that the omission and/or misrepresentation of any fact from or on this application or during any interview will result in immediate rejection of my application or if I am hired will be cause for immediate dismissal.  Unless I noted otherwise, I authorize the Company to independently contact all my employment references and personal references, as well as the education institutions I have attended.  I further authorize the Company to independently inquire about, investigate and obtain copies of any records which relate to me from my former employers and educational institutions.  I hereby release the Company and all affiliated persons and entities, as well as any person or institution that provides the Company with any lawful information about me, from any and all liability whatsoever resulting from any such lawful independent inquiry, investigation or communication.</p><p>I understand that any offer of employment is conditional upon complying with the Company\u2019s requirements, which may include, but not be limited to, depending upon the job position and applicable law: executing a separate Consent and Authorization to conduct a background check, a review of references, and a review of background check information including criminal conviction information. I agree to execute any consent forms necessary for the Company to conduct its lawful post-offer, pre-employment checks. I also understand depending on the position applied for and subject to applicable law, that if offered employment I may be required to successfully pass a post-offer, pre-employment drug screen and a post-offer medical examination (as applicable, depending on the job.) Failure to pass such post-offer, pre-employment drug screen will result in the Company rescinding my offer of employment and no further action will be taken regarding my application for employment, except as may otherwise be required by law.</p><p>I understand that the Company recommends that I do not resign from my current job until post-offer, pre-employment background checks and, where applicable, a drug screen have been completed to the Company\u2019s satisfaction.</p><p>If hired, I understand that I will be required to abide by all of the rules and regulations of the Company.  I understand that nothing in this application shall constitute an offer, a contract or a guarantee of employment for a specific period of time.  If hired, I understand <b>that my employment may be terminated with or without cause and with or without notice at any time, at the will of the Company or me.  I further understand that no representative or agent of the Company, other than the appropriate Human Resources representative has the authority to enter into any agreement for employment, on an individual or collective basis, for any specific period of time, or to make an agreement contrary to the foregoing.  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