Release Form

Please Read Carefully and Sign Below:

I hereby certify that I have not knowingly withheld any information that may adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed the application. I understand that any omission or misstatement of material fact on this application or any documentation used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further authorize the references I have listed to disclose to the company and all letters, reports or other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

I understand that nothing contained in the application, or conveyed during my interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed my me and the company's designated representative.

Applicant's Signature *

Signature is required

Applicant's Name *

Name is required

Date *

Date is required

National Criminal History Check

Subject Information:

Telephone Number *

Last Name *

Last name is required

First Name *

First name is required

Middle Initial

Date of Birth *

Date of birth is required

Sex *

Please select sex

Race

Social Security No. *

SSN is required

Signature *

Signature is required

Date *

Date is required

Employment Verification

I, authorize the release of any information concerning my previous employment to Nightingale.

Name is required

Signature of Applicant *

Signature is required

Date of Signature *

Date is required

Do not fill out information below this line.

To:

Attn:

Address:

Re:

S.S. #

All information will be held in complete confidence

Relationship to Applicant:

Employer

Supervisor:

Other (Specify):

Position Held:

From: (dates)

TO:

Salary

Reason for Leaving:

Would You Rehire?

Yes

No

Criteria	Excellent	Good	Fair	Poor	Unacceptable	N/A
Quality of Work
Job Knowledge
Skill Proficiency
Judgment
Initiative
Cooperation
Attendance
Promptness
Appearance
Teamwork
Organizational Skills
Overall Performance

Comments:

Signature

Title

Date