Answering "Yes" to these questions does not constitute an automatic rejection of employment. Date of the offense, seriousness and nature of the violation, rehabilitation and position applied for, will be considered.

Please furnish the names, addresses and phone numbers of two people whom you are not related to and whom you have not been employed:

I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, educational, financial, or medical history and other related matters as may be necessary for an employment decision. I hereby release employers, schools or persons from all liability when responding to inquiries in connection with my application.

In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in discharge.