Nurse Practitioner – Physician Assistant – Job #337

I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever, I agree that my employer shall not be liable in any respect if my employment is terminated because of the falsity of statements, answers or omissions made by me in the questionnaire. I authorize employers, companies, schools or persons named above to give any information regarding my employment, together with any information they may have regarding me whether or not it is in their records. I hereby release said employees, companies, schools or persons from all liability for any damage both legal and otherwise, for issuing this information. I also understand a conditional offer of employment may be based on results of a later medical examination. In addition, if accepted for employment, I hereby agree to abide by the rules and policies of my employer.

Further, I understand that any employment is not for a stated period of time and may be terminated with or without cause, at any time, at the option of either myself or my employer. In addition, should my employer be or become subject to the conditions of the Drug-Free Workplace Act of 1988, I agree to abide by such established policies as relates thereto.