I hereby give you my permission to contact the above employers, references, and educational, licensing, credentialing and certification institutions to verify the items I listed above. I hereby release Gunnisonville Meadows Assisted Living, Inc. and the above referenced organizations, reference persons and employers from all claims, liability and damages that may result from furnishing the information to you. I consent to releasing any information relating to my job performance which is documented in my personnel file. In the event that a prior employer or other organization is obligated to provide any written notice to me regarding the disclosure of information to Gunnisonville Meadows Assisted Living, Inc., I hereby waive that obligation and expect no written notice of disclosure of my personal information.
I also understand that because of the nature of my job and licensing requirements, I hereby consent to the release of this application or portions of this application to representative of the Department of Human Services, Department of Community Health, local community mental health entities or other governmental agencies or private agencies, for all licensing or investigatory purposes and to verify information I have listed in this job application. I hereby release Gunnisonville Meadows Assisted Living, Inc., the Department of Human Services, Department of Community Health, local community mental health entities and other governmental agencies or private agencies from all claims, liability, and damages that may result from furnishing the information to you.
I further specifically waive written notice and agree to the divulging of any disciplinary reports, letter of reprimand or other disciplinary action by all prior employers, and hereby release any prior employers from all claims, liability and damages that may result from furnishing the information to you.
I certify that all of the information provided on this application is true, complete, and correct. I further understand and agree that any falsification, misrepresentation or omission of fact on this application or in any interviews or pre-employment process is grounds for disqualification for consideration for employment or termination of employment if the discovery is made after employment begins.
