MDS RN

Employer #2

Employer #3

Second Reference

Third Reference

Applicant's Statement

I certify that answers given herein are true and complete to the best of my knowledge, and understand and agree that any misrepresentation or omission on my application or related papers, or made during any oral interviews may result in refusal of employment or shall be considered grounds for dismissal.

St. Augustine Health Ministries may make an investigation of my history and may verify all data given in my application of employment, and that if hired, my employment is at will, for no definite period, and my be terminated at any time without prior notices, without liability for wages, salary or any benefits except those earned up to the date of termination. If employed by St. Augustine Health Ministries, I agree to undergo medical examinations, including drug and alcohol testing, at any time at the option of St. Augustine Health Ministries, and I also understand and agree that i will abide by its rules and regulations.

If separated from employment from St. Augustine Health Ministries for any reason, I authorize it to furnish any information to employment references and release from liability it and/or any person giving or receiving any such information.