Authorization For Release of Information
I hereby give my permission to Misericordia Nursing & Rehabilitation Center to conduct reference checks with former employers, educational institutions, business or personal references to certify that the information that I have provided is true and complete.
I understand that Misericordia Nursing & Rehabilitation Center will check my references and background, and that whether or not I am considered for a position depends on the results of this check. I further agree and understand that if employed, Misericordia Nursing & Rehabilitation Center, may seek any information from whatever source in which its discretion is deemed relevant to my employment.
I also authorize any of my prior employers, educators, references and any other persons listed on my application to answer qu4estions about my ability, my character, my reputation and my previous employment record.
I hereby release Misericordia Nursing & Rehabilitation Center, its agents, officers, directors, employees, previous employers from all liability of any kind, including any damages on account of furnishing such information.
My name and date serve as my electronic signature.
List name and telephone number of three work references, who are not related to you and who are not previous supervisors.
Data Record - VOLUNTARY
Applicants are considered for all positions, and employees are treated without regard to race, color, religion, sex national origin, age, martial or veteran status, disability or other legally protected status.
As an employer, we comply with government regulations. This data record will be physically separate from your employment application before the application is considered for possible employment.
I hereby certify that the information set forth on the this application is true and complete to the best of my knowledge. I understand that if employed, false statements made in this application shall be sufficient cause for termination.
My name and date below serve as my electronic signature.
Beth Waltemire, Director Human Resources