In consideration of my application, I authorize Hospice & Palliative Care of Iredell County, Inc, by and through QPI to verify all data given by me on application, related papers or oral interviews. I understand a thorough investigation may be conducted which may include but not be limited to criminal history, motor vehicle driving record, education verification, employment history, credit report and personal history. I hereby authorize employers, agencies, personal references and other persons with whom I am acquainted to answer all questions and release all information concerning my employment record, character, reputation, ability, education, military service, credit history and other applicable reports. Furthermore, I release all agencies, bureaus, employers, information service organizations, and individuals or companies named above from all liabilities of damages that might result from information provided in good faith. I state that the information provided by me on my application is accurate and I agree that if any information therein is found to be false at any time, my application may be discarded or my employment terminated. I understand that the information requested below regarding sex, race and date-of-birth are for the sole purpose of gathering the above information accurately and will not be used to discriminate against me in violation of the law.

I certify that all the information contained in my employment application is true to the best of my knowledge. I further understand that if I am given the opportunity to begin employment with Hospice & Palliative Care of Iredell County, prior to completion of my background investigation and it is determined that I gave false statements, or any omission of a material fact, I may be subject to immediate discharge.