(Note: Conviction of a criminal offense will not necessarily preclude your employment.)

Person to be notified in case of accident or emergency.

Dates of Duty

To:

This institution does not discriminate in hiring or in any other decision on the basis of race, color, sex, citizenship, national orgin, ancestry, Vietnam era veteran status, or on the basis of age or physical or mental disability unrelated to ability to preform the work required. No question on this application is intended to secure information to be used for such discrimination.

I voluntarily give this institution the right to make a thorough investigation of my past employment and activities, agree to coorperate in such investigation and release from all libility or responsibility all persons, companies or corporations supplying such information. I consent to take the physical examination and such future physical examinations as may be required by this institution at such times and places as the institution shall desginate. I understand that an offer of employment may be contigent on passing the physician examination which relates to the essential duties I would be required to preform.

I understand that my employment is at will and that either party is free to terminated the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form.

If employed, I will be required to complete an Employment Verification Form (1-9) and within three days show satisfactory evidence of identity and eligibility for employment.