Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

If you answered "no" to rehire eligibility or you possess any other pertinent information, positive or negative, regarding the named applicant's ability, character, and/or integrity, the signature below gives you the authority to share the information. Please describe:

I hereby authorize any person, company, or organization to furnish FACILITY/AGENCY NAME with the answers to the questions regarding my employment record.

For FACILITY/AGENCY NAME to consider my application for employment, I hereby release all liability created by this inquiry into my employment record, by the communication of the requested information, or by any action taken by FACILITY/AGENCY NAME based on that information and from any other claim for relief of any kind and from any and all causes of action which I might otherwise assert based upon said inquiry, communication, or action.

If you answered "no" to rehire eligibility or you possess any other pertinent information, positive or negative, regarding the named applicant's ability, character, and/or integrity, the signature below gives you the authority to share the information. Please describe:

I hereby authorize any person, company, or organization to furnish FACILITY/AGENCY NAME with the answers to the questions regarding my employment record.

For FACILITY/AGENCY NAME to consider my application for employment, I hereby release all liability created by this inquiry into my employment record, by the communication of the requested information, or by any action taken by FACILITY/AGENCY NAME based on that information and from any other claim for relief of any kind and from any and all causes of action which I might otherwise assert based upon said inquiry, communication, or action.