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I AUTHORIZE OCCUPATIONAL HEALTH PARTNERS (the “COMPANY”) TO VERIFY ALL STATEMENTS CONTAINED ON THIS APPLICATION. I ALSO AUTHORIZE THE COMPANY TO CONTACT MY PRESENT EMPLOYER, PAST EMPLOYERS, REFERENCES, SCHOOLS AND ORGANIZATIONS. I AUTHORIZE ANY PERSON, SCHOOL, EMPLOYER, OR ORGANIZATION TO PROVIDE THE COMPANY WITH INFORMATION AND OPINION AND RELEASE THE COMPANY AND ALL SUCH SOURCES FROM ANY LIABILITY ARISING FROM THE SOLICITATION OR USE OF THE INFORMATION.

BY SUBMITTING THIS APPLICATION ONLINE AND PROVIDING MY INITIALS BELOW, I STATE THAT THE INFORMATION PROVIDED ON THIS EMPLOYMENT APPLICATION AND ON MY RÉSUMÉ, IF ANY, IS TRUE AND COMPLETE AND THAT THERE IS NO INFORMATION WHICH I HAVE OMITTED OR FAILED TO INCLUDE.

I AGREE THAT ANY FALSE INFORMATION OR OMISSIONS, INTENTIONAL OR UNINTENTIONAL, ON THIS EMPLOYMENT APPLICATION WILL DISQUALIFY ME FROM CONSIDERATION FROM EMPLOYMENT AND, IF EMPLOYED, MAY RESULT IN IMMEDIATE DISCHARGE.