I certify that the statements I have made are true and correct and without material omission. I understand that making false statements or omitting pertinent facts is sufficient cause for rejection or dismissal from employment. I authorize obtaining information from any person(s), employers, educational institutions, licensing authorities, and/or law enforcement agencies concerning my background, work habits, skill or conduct on the job, with the exception of past employer(s) I have indicated that are not to be contacted. I hereby release such person or entities from all liability for damages for issuing such information.

When I am employed I agree that if at any time I make claims for personal injuries, I will submit myself, upon written request, to examination by a physician or physicians of employer's selection, at employer's expense, as often as may be requested.

I also agree that if I am employed, now or at any time in the future, my employment may be terminated at any time without liability to me for wages or salary except for such wages or salary which I earned prior to the date of my termination.

I am aware that Public Law 91-508, known as the Fair Credit Reporting Act, requires the employer to inform me that a routine inquiry may be made that will provide applicable information concerning my character, my general reputation, my personal characteristics and my credit history. Upon written request, I will provide additional information as to the nature and scope of the inquiry or any report which is produced.