It is understood and agreed that any offer of employment to the applicant is predicated upon the truthfulness of the statements herein contained. False information given by the applicant may be used as a basis for discharge after employment has been actually secured by the applicant.

I hereby authorize any person, firm or corporation to furnish DCMH/PHC any information concerning my character, habits, law violations, if any, ability, financial responsibility, and particularly the cause of the termination of employment at any time, and hereby release them from any liability for damages on account of furnishing such information. DCMH/PHC is an equal opportunity employer.

This application will not be considered unless all questions are answered. Please fill out each question completely.