I certify that all statements given on this application and all other information provided are true and accurate, and I understand that falsification, omission, or misrepresentation in this or any other personnel record can result in my termination, if hired. I authorize verification of all statements contained in this application (and the accompanying resume, if any). I authorize Peoria Ear Nose and Throat Group, S.C. to contact my present employer (unless otherwise noted in this application form), past employers, and listed references. I authorize any person, school, current or previous employer, and organizations including state, local, or federal law enforcement authorities to provide Peoria Ear Nose and Throat Group, S.C. with relevant information regarding my work history and personal background, including but not limited to education, professional licensing, criminal history, driving history, personal character, abilities, work habits, mode of living, residency, immigration status, general reputation, performance, experience and other qualities pertinent to qualifications for employment, including reasons for termination from past employment, and I release Peoria Ear Nose and Throat Group, S.C. from any legal liability in connection with the request for and release of such information.

I authorize Peoria Ear Nose and Throat Group, S.C. to conduct any and all such background investigations as it deems necessary, including but not limited to an investigation of police records and a protective services background check. By completing and signing this form, I authorize, without reservation, any party, including but not limited to employers, law enforcement agencies, state agencies, institutions and private information bureaus or repositories, contacted by Peoria Ear Nose and Throat Group, S.C. to furnish any or all of the above listed information. My signature below releases Peoria Ear Nose and Throat Group, S.C. from any and all liability for damages arising from the investigation and disclosure of the requested information. Further, it releases and discharges all liability from all companies, agencies, officials, officers, employees and other persons who, in good faith, provide to Peoria Ear Nose and Throat Group, S.C. the above-mentioned information as requested, in order to successfully complete a background investigation.

I agree that if I am offered employment by Peoria Ear Nose and Throat Group, S.C. and accept, my employment will be employment “at will” and that my employment can be terminated, with or without cause, and with or without notice, at any time, at the option of either Peoria Ear Nose and Throat Group, S.C. or me. I understand that neither this application nor any other personnel form will constitute a contract for employment, and that the Company may change the conditions of employment, including but not limited to compensation and benefits, at any time. If hired, I agree, as a condition of employment, to keep confidential and not disclose to anyone all information acquired during employment which is of a confidential, proprietary, or privileged nature.

I understand that Peoria Ear Nose and Throat Group, S.C. is an Equal Opportunity Employer and does not discriminate in employment. It is understood that no question on this employment application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state, or federal law.

Your signature authorizes a photocopy or fax copy of this authorization to be as valid as the original.