AUTHORIZATION & WAIVER
I hereby certify that the information I have provided verbally and on my application and accompanying resume and documents, if any, is true and complete. I have not knowingly withheld any information that might, if disclosed, would affect my application unfavorably. I understand, and agree, that any information provided by me, either written or verbal, which proves to be false, misleading, or incomplete, may prevent me from being hired. If hired, this may be grounds for discipline or dismissal from employment if discovered at a later date.
I authorize Pines Behavioral Health Services (“PBHS”) to make any investigation into my background deemed necessary, including, but not limited to, investigation and verification of references, educational transcripts and records, employment records, disciplinary information, and criminal conviction history. I authorize all references, previous employers, schools, educational institutions, military organizations, and other persons having information about me in order to release to PBHS any and all information and opinions concerning me - personal or otherwise - whether or not such information is part of their written records, including disciplinary, academic, service or performance records, without providing me notice of such release. I also authorize and request federal, state, and local governmental agencies to release to PBHS any information requested concerning any criminal convictions on my record.
Without limitation, I release all parties mentioned in this paragraph from any and all liability and damages for releasing such information. I specifically release PBHS, its governing board, officers, employees, and/or agents from any and all claims and/or liability whatsoever for any damages or consequences which result from its investigation of me. A photocopy of this signed authorization and waiver shall be as valid as an original.