315 West Hickory Street • Sylacauga, AL 35150

An Equal Opportunity Employer

Coosa Valley Medical Center does not discriminate in hiring or employment on the basis of race, color, religion, creed, sex, national origin, age (over 40), disability, status as a disabled or Vietnam era veteran, or because of citizenship status in the case of a citizen or intending citizen. No question on the application is intended to secure information to be used for such discrimination. Coosa Valley Medical Center complies with all applicable state and federal laws.



PLEASE TAKE THE TIME TO READ THE FOLLOWING MATERIAL. IT APPLIES TO YOU. IT WILL GOVERN ALL FUTURE LEGAL DISPUTES BETWEEN YOU AND COOSA VALLEY MEDICAL CENTER, INC. (CVMC). By signing or submitting this application, you are agreeing to submit all claims against CVMC to binding arbitration. Please read the following very carefully because it will govern your employment at CVMC.

In consideration for Coosa Valley Medical Center (CVMC) agreement to review this application, and also in consideration for CVMC. agreement to submit any claims it may have against me, now or in the future, to arbitration, I agree and represent as follows: by signing or submitting this application, I agree that any dispute that I may have with CVMC, or that CVMC may have with me, will be handled in accordance with Coosa Valley Medical Centers Dispute Resolution Program under which binding arbitration is the exclusive method for deciding any legal claims I may have against CVMC (including any claims that I may have against the facility for refusing to hire me), or that CVMC may have against me; neither CVMC nor I will have any of our claims heard and decided in court. The Dispute Resolution Program includes all claims or controversies, whether or not arising out of employment or termination of employment, that would constitute a cause of action in a court, including but not limited to claims for wages or other compensation due; claims for breach of contract or promise (express or implied); tort claims; claims for discrimination or other employment-related claims; claims of retaliation for filing or prosecuting workers. compensation claims; claims for benefits (except where an employee benefit or pension plan specifies that its claims procedure shall result in an arbitration procedure different from this one); and claims for violation of any federal, state, local, or other governmental law, statute, regulation, or ordinance (including but not limited to claims based on the Civil Rights Act of 1991, Title VII of the Civil Rights Act of 1964, the Civil Rights Act of 1866, the Americans with Disabilities Act, the Rehabilitation Act of 1973, the Age Discrimination in Employment Act, the Older Workers Benefit Protection Act, the Family and Medical Leave Act, the Employee Retirement Income Security Act of 1974, the Equal Pay Act, the Fair Labor Standards Act, the Vietnam Era Veteran’s Readjustment Assistance Act, the Uniformed Service Employment and Reemployment Rights Act of 1994, the Worker Adjustment and Retraining Notification Act, or the Fair Credit Reporting Act, the Alabama Constitution, the Alabama Age Discrimination in Employment Act, and any amendments to any of the foregoing), except claims for workers compensation benefits and unemployment compensation benefits. Nothing in the Program shall be construed as prohibiting me from filing an administrative charge of discrimination, an unfair labor practice charge, or other alleged violations of the law with the Equal Employment Opportunity Commission, the National Labor Relations Board, or any other government agency acting pursuant to state or federal law. Also excluded are certain claims by the Coosa Valley Medical Center for injunctive or equitable relief to protect trade secrets and other confidential matters.

I further understand that a copy of Coosa Valley Medical Centers Dispute Resolution Program is available for me to review prior to my signing or submitting this application, and that I have either reviewed the Program or have voluntarily decided to be bound by it without reading it. That Program is incorporated into this Application by reference. By signing or submitting this application, I agree and represent that I am not relying upon any representation not contained in this application or the Program document.


Contact Information

Current Address

General Information

Have you ever been employed by any division of Coosa Valley Medical Center or any affiliated organization? *
Please identify any relatives you have who work for you at Coosa Valley Medical Center:

Employment Preference

Are you seeking: *
Days Available *
What shifts are you willing to work? *


(List Name and Location [City and State] of School)

Professional Licenses and/or Certifications

Has your professional License ever been Revoked?
Have you ever received discipline under your professional license/registration? Has your professional License ever been Suspended?
Have you ever been excluded from participation in Medicare, Medicaid and/or any other federally funded program

Employment History

Employer 1
May we contact?
Employer 2
May we contact?
Employer 3
May we contact?


Reference 1
Reference 2
Reference 3

Additional Skills

Public Records

Have you since your 18th birthday ever been convicted or pled guilty to any felony? *
Have you since your 18th birthday ever been convicted or pled guilty to any Misdemeanor other than for a minor traffic violation *
Do you currently have charges pending? *
Are you currently on probation? *


I authorize Coosa Valley Medical Center to investigate all statements made in this application and hereby release from liability all persons, companies or corporations supplying any information concerning me. I hereby appoint the Coosa Valley Medical Center as my agent for the collections of all such information regarding me. I understand that any omissions or false statement will be cause for dismissal.

I understand that any job offer may be contingent upon a post-offer physical examination, reference checks, and other requirements for the position as determined by the company, and I agree to submit to such a physical examination by a medical doctor designated by CVMC when requested at CVMC' expense. The physical examination will include a medically approved laboratory test for the detection of narcotics or other drugs and alcohol, the presence of which may effect the applicant's performance as an employee, and may be used as grounds for denying employment.

I understand that if I am employed by Coosa Valley Medical Center, the employment relationship between me and the company may be terminated by either party at any time, with or without cause. I further understand that, if I become employed, I will be required either to participate in a CVMC health insurance plan, or to maintain comparable health insurance at my own expense. I understand that this employment-at-will relationship cannot be altered except through a written employment contract signed by me and the President of CVMC. I further understand that as a condition of employment, I agree to arbitrate any and all disputes that I may have with Coosa Valley Medical Center, except as specifically provided in the program document.

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