Authorization to Provide Information and Release of Liability:
As an applicant for the Bartlett Regional Hospital I have been requested to provide information for use in determining my qualifications for employment. In connection with my application, I authorize you to disclose to representatives of the Bartlett Regional Hospital any and all information you have concerning my employment with you including, but not limited to, evaluations and other information contained in my personnel file.
A photocopy of this document shall be considered as valid as the original. The authorization to provide information shall expire one year after the date of signature below.
Read the following carefully before signing:
Under penalties of perjury, I declare that my answers to the questions on this application and any necessary examinations and supplements are true and give BRH the right to investigate all information given and to secure additional appropriate information if necessary. I understand that an investigation report may be made from the information obtained through personal interviews with others. I understand that this inquiry may include information as to my personal characteristics, employment verification, credential verification, personal identity verifications, reference checks, criminal records, motor vehicle records, and appropriateness for employment. I authorize my current and former employers to give information regarding my employment, together with all information regarding me, and hereby release from all liability to responsibility all persons, companies, or corporations furnishing such information in good faith. I also authorize the release of my scholastic ratings to BRH by school and other post-secondary institutions I have attended.
I understand that the completion of this application does not assure me of a position with BRH and does not obligate BRH to me in any way. I further understand that any misrepresentation herein may cause my application to be rejected, and may be grounds for immediate dismissal. Candidates selected for hire must pass a health screen and fingerprint criminal background check. I understand that BRH may require me to submit to a drug screening process. I understand that this application, exam documents, and attachments become a part of BRH records and will not be returned. I certify that to the best of my knowledge all the statements are true, correct, and complete and made in good faith.
My typed name below shall have the same force and effect as my written signature.
