APPLICANT INFORMATION

EDUCATION

MILITARY SERVICE

PREVIOUS EMPLOYMENT (MOST RECENT FIRST)

PROFESSIONAL REFERENCES

Please list three professional references.

GENERAL

DISCLAIMER, AUTHORIZATION AND SIGNATURE

I certify that the facts contained in this application are true, correct and complete to the best of my knowledge and understand that falsified, misleading, misrepresentation, or omission of any information submitted in connection with my application or interview, whether in this document or not, may result in rejection of my application or, if hired, in dismissal.

I authorize investigation of all statements contained herein and the references and employers listed above to give any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information. I waive written notice from my current employer and from any of my former employers regarding the disclosure of disciplinary reports, letters of reprimand, or other notices of disciplinary action contained in my personnel records (even if more than four years old). This waiver is made pursuant to the employee right-to-know act.

I authorize the references and current and former employers listed in this application to give you any and all information concerning my current and previous employment and any pertinent information they may have (even if more than four years old) and release all parties from any liability for any damage that may results from furnishing same to you.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or into any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

Background Check Disclosure and Authorization

I hereby authorize Selective Case Management, Inc. (SCM) and its representatives to run a
complete background check including, but not limited to education, references, and criminal
history which may be in any state or local files, including those maintained both public and private
organizations for employment purposes.

I specifically authorize my former employers and their representatives to release information
from my personnel file pertaining to performance and the reason for separation. Selective Case
Management, Inc. shall retain the signed copy of this authorization in its files.

I agree information provided is accurate and true. I execute this release with the full knowledge
and understanding that information obtained will be kept confidential, used only for vocational
purposes.

By providing the digital indication of my signature below, I am aware it will be regarded as equivalent to my handwritten signature. My electronic signature confirms that I have reviewed my application for accuracy and completeness and provides consent for Selective Case Management and/or it’s representative’s to conduct and obtain any/all background information relevant to potential employment.

CONFIDENTIAL MATERIAL: This document is property of Selective Case Management, Inc. and its representatives.
Unauthorized use of this document and information is strictly prohibited. Selective Case Management, Inc. is an
equal opportunity employer.