Applicants Certification and Agreement (Please read carefully):
By checking the box below, I certify that the answers given by me to the foregoing questions and statements are correct without consequential omissions of any kind whatsoever. I do agree not to hold United Ambulance Service liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me in the questionnaire. I authorize nursing homes, hospitals, companies, or person’s names as former employers to give any information regarding my employment and I hereby release said employers from all liability for any damages for issuing this information.