Radiologist

I certify that all information I will provide is true, complete, and correct. Any information provided found to be false, incomplete or misrepresented in any respect, will be sufficient cause to cancel further consideration of this application, or immediately terminate me from the employer’s service, whenever it is discovered.

I authorize and request that my former/current employer, listed on this form, complete the form where indicated and release any additional information about my job performance that they may have upon receiving a further inquiry. My signature indicates my approval for this process and for the release of any such information requested during the reference. I waive all claims, any right of action, cause of action, or other means of redress related to both the completion of this form by my former/current employer and any further disclosure of information about me and I release all prior employers from whom such information is obtained from any and all liability for damages of whatever kind or nature which may at any time result to me on account of compliance, or any attempts to comply, with this authorization.

I understand that the prospective employer does not unlawfully discriminate in employment and that no question will be used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state, or federal law. Finally, to the extent I have signed with my prior employer any document by which the prior employer promised not to disclose information requested on this form, I waive all rights to enforce such a promise and release my prior employer from any such non-disclosure obligation. I certify that I have read, fully understand, and accept all terms of this statement.

By selecting yes, you agree to the above statement.