APPLICANT'S STATEMENT

In making this application for employment. I understood that an investigation may be made whereby information is obtained through personal interviews with my former and present employers, work and personal references. This inquiry includes information as to my character, general reputation, personal characteristics and mode of living.

I authorize former and present employers, work and personal references listed and any other individuals I may name to give the Practice or its designee any and all information concerning ,my previous employment and any pertinent information they may have, personal or otherwise and release such parties from all liability for damages that may result from fumishing same to this practice.

I understand that this application, interview and other practice documents are not promises of employment. Should i be employed, I understand that my employment will be on a trial period for ninety days from my start date. I further understand that, if I am employed, I can terminate my employment with or without cause and with or without notice, at any time and the practice has a similar right. The physician or my manager may require sepicific performance and/or productivity that may change from time to time, and such requirement and performance may be the basis of continued employment

I understand that the prectice prohibits the use of illegal drugs, and I will be Drug Tested.

The information given by me in this application is true and complete in all respects, and I agree that if the information is found to be false, misleading or unsatisfactory in any respect (in the exclusive judgement of the practice) that I will be disqualified from consideration for employment or subject to immediate dismissal if discovered after I am hired.