Give employment record as completely as possible listing current or most recent employer first. Show unemployed or self-employed periods and indicate dates and comment on each period. Include part time or summer work.

I certify that the statements made on this application are true and correct to the best of my knowledge and belief and hereby grant permission to verify such answers. I understand that any false statement on this application may be considered as sufficient cause for rejection of this application, or for dismissal if such false statement is discovered subsequent to my employment. I further understand that a preemployment investigation will be performed to determine my suitability for employment and I authorize written access to any records concerning my education, employment, or criminal background. I understand that if any injury is made, all information as to it's nature and scope will be supplied upon request. If this application is considered favorably, I may have to pass a physical examination as condition of employment, and I agree to abide by and comply with all rules of this facility. I understand and agree that, if hired, my employment is for no defined period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any prior notice.