Employment Application Form

High School

College/University

Professional/Tech School

Equal Employment Opportunity Employer

Accuracy of Information/Background Check

I hereby certify that the information is this application is correct and compete to the best of my knowledge. I understand that falsification or omission of any material information on this application, in the interviewing process or in my resume, or failure to pass a physical examination, may be sufficient cause for immediate termination if I have already received an offer of employment. I understand that this application will no longer be active or receive further consideration once the position for which I am applying has been filled, or if I am employed but do not actively work for Accredited for a period of six months or more.

I agree to have any of the statements herein as well as my background investigated by Accredited or its agents. This authorization shall become effective immediately and shall remain in effect for a period of twelve months after the date of signing this authorization. I understand that the background investigation may include, but is not limited to, reviewing my education, employment history, any public records, and personal references, whether through a search of my Social Security number, name, or other identifying information. In reviewing my employment history, I understand that Accredited may contact any or all of my listed previous employers, and I consent to Accredited doing so. In consideration for reviewing my application and other related information, I hereby waive and release Accredited, its employees and agents, and all other entities and persons from any claims I might have, including defamation and invasion of privacy, arising out of any verbal or written inquires and/or any verbal or written responses related to investigation of my background as well as the use or disclosure of such information. I understand that a photocopy of this authorization is to be considered as valid as the original.

EMPLOYMENT “AT WILL” DECLARATION

LIQUIDATED DAMAGES

CONFIDENTIALITY/ HIPAA AGREEMENT

MEDICAL PROVIDER NETWORK (MPN)

AUTHORIZATION TO CORRECT FOR PAYROLL ERRORS

AUTHORIZATION FOR RELEASE OF INFORMATION

APPLICANT VERIFICATION DATA