PRESENT & FORMER EMPLOYER(S) (Please list your current, as well as, your 3 previous employers, starting with the most recent. Please do
not
leave any information blank.)
Current Employer Previous Employer Previous Employer CERTIFICATION I understand that false or inaccurate information in this Application will be a basis for termination from
employment, denial of workers' compensation benefits, and/or unemployment compensation benefits. I authorize
the
Company to investigate my background and verify this information. I further authorize the Company to release
the
information contained in this Application to its customers, insurance company representatives, and/or legal
counsel.
I understand and agree that I will be employed at-will by the Company. I understand that this means that
either
the Company or I may terminate my employment at any time for any or no reason. I have reviewed and
understand this
Application and I agree to follow the policies and procedures set forth in this Application. I understand
that
nothing in this Application alters or changes my employment-at-will status. I also recognize that the
Company, at
its sole discretion, may add to, revoke, or modify the policies, practices and procedures contained in this
Application.
I, hereby declare that all statements contained in this Application are true and accurate.
