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Name
Nature Of Relationship
Phone Number/Address
Years Known
Personal/Professional References (Persons not related to you)
I understand that employment is contingent upon verification of education and satisfactory
previous employment records and all required submitted paperwork. I understand that if I am employed for an indefinite period of time “at-will” and that the center can change wages, benefits and conditions at any time. The facts Ihave set forth in this application are true and complete. I understand that if I am employed, false
statements made on this application shall be considered sufficient cause for dismissal. I agree if
employed to serve to the best of my ability and to abide by the policies established by the center. I hereby authorize present and former employers and/or schools that I have attended to release to the center and information concerning my present or past employment and/or school records.
This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the American’s With Disabilities Act (ADA) and other relevant federal and date laws.
The center is an equal opportunity employer.
Date_________________ Signature _________________________________________
In Case Of Emergency Contact:
Name
Relationanship
Phone
Office Use:
Remarks: