Disclaimer and Personal Information Release Information



I certify that all information provided in order to apply for and secure work with the employer is true, complete and correct.

I understand that any information provided by me that is found to be false, incomplete, or misrepresented in any respect, will be sufficient cause to (1) cancel further consideration of this application, or (2) immediately discharge me from the employer's service, whenever it is discovered.

I expressly authorize, without reservation, the employer, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me.

I understand that the employer does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.
I understand this application remains current for 365 days. At the conclusion of that time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.

If am hired, I understand that I am free to resign at any time, with or without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative or the employer is authorized to make any. assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by the board.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an 1-9 Form in this regard.


Personal Information Release:


I do hereby authorize a review and full disclosure of all records concerning myself to any duly authorized of the Pike 911 Board, whether the said records are of a public, private, or confidential nature.

The intent of this authorization is to give my consent for full and complete. disclosure of any and all records of educational institutions; financial or credit institutions; including records of loans; the records of commercial or retail credit agencies (including reports and/or ratings) and other financial statements and records wherever filed; medical and psychiatric treatment and/or consultation, including hospitals, clinics, private practitioners, and the U. S. Veteran's Administration; current employment and previous employment records, including background reports, efficiency ratings, complaints or grievances filed by or against me; records and recollections of attorneys at law, or other counsel, whether representing me or another person in any case, either criminal or civil, in which I presently have or have had an interest; traffic and criminal history records, and records involving-any incident -where have been convicted of a crime. The records referred to in this paragraph shall include, but are not limited to papers, documents, recordings and photographs, whether on paper or stored/transmitted electronically.

I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release, may be considered in determining my suitability for employment by the Pike 911 Board whether the position sought is a paid or unpaid position, voluntary or educational in nature. understand that (1) the Pike 91 1 Board states that the use of such information will be in accordance with its employment policies and that such information will not be used for any other purpose other than for consideration of the undersigned as an employee of the Pike 91 1 Board, and (2) this background investigation is required because of the nature of the particular position that I have made application for, in that it involves a sensitive position or that I may be working in an area where confidentiality and security is imperative. I also certify that any person(s) who may furnish any such information concerning me shall not be held accountable for giving this information; and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. I further release any employee(s) of Pike 911 Board who conducts any part of my background investigation from any and all liability resulting from such investigation.

A photocopy of this release form will be as valid as an original thereof, even though the said photocopy does not contain an original writing of my signature.