STATEMENT OF DISCLOSURE:
I hereby declare that all statements contained in this application are true and correct and I understand that false,inaccurate, or incomplete information, or omissions on the application will be basis for rejection, or may be cause for subsequent termination if I am hired. I hereby authorize Modern Dental Care to investigate my background and verify this information. I understand that, if employed, my employment will not be for any fixed period of time and may be terminated by Modern Dental Care or myself at any time. I also understand that my failure to report to work will indicate that I have quit.
REFERENCE RELEASE FORM:
I voluntarily and knowingly authorize any former employer, person, firm corporation, school or government agency, its officers, employees and/or agents to release any and all information concerning my former employment, education, and/ or background information to Modern Dental Care, its officers, employees, and/or agents, making a written or oral request for such information. I understand that the information may include, but is not limited to, performance evaluation and sports, job descriptions, disciplinary reports, letters of reprimand, grades, and opinions regarding my suitability for employment possessed by it. I recognize that a copy of this authorization and release is as valid as the original and should be considered as such.
I voluntarily and knowingly, fully release and discharge, absolve, indemnify and hold harmless such former employer, person, firm, corporation, school or government agency, its officers, employees and agents from any and all claims, liability, demands, causes of action, damages, or costs including attorney's fees, present or future, whether known or unknown, anticipated or unanticipated, arising from the disclosure or release; except for the malicious and willful disclosure of derogatory facts which the officer, employee, or agent disclosing such facts knows are untrue.