HIGHEST DEGREE EARNED
PROFESSIONAL LICENSES AND/OR CERTIFICATIONS
YES
IF LICENSED, REGISTERED, OR CERTIFIED
TYPE STATE ISSUED DATE NUMBER REVOKED, SUSPENDED, OR ON PROBATION
PLEASE LIST NAME, ADDRESS AND PHONE NUMBER OF PREVIOUS EMPLOYERS WITH THE MOST RECENT EMPLOYER FIRST.
PROFESSIONAL REFERENCES
(LIST 3 PROFESSIONAL REFERENCES IN WHICH YOU'VE WORKED WITH DIRECTLY AND CAN EVALUATE YOUR ABILITIES WITHIN A WORK ENVIRONMENT.)
READ THIS SECTION PRIOR TO PROVIDING SIGNATURE BELOW

In consideration of my employment, I agree to conform to the rules and regulations of this facility. I understand that my employment can be terminated at any time and for any reason, at the option of either the facility or myself. I understand that no one has any authority to enter Into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing, except for a written employment agreement signed by an administrative representative of this facility. I understand any offer of employment is contingent upon successful completion of multiple pre-employment screenings.

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions may disqualify me for further consideration for employment and may result in discharge even if discovered at a later date.

I hereby authorize persons, schools, my current employer (if applicable) and previous employers and organizations named in this application (and accompanying resume) to provide this facility and all affiliates with any relevant information regarding an employment decision, and I release all such persons from any liability regarding the provisions or use of such information.

We want to make sure you are a human and not a robot.