By signing below, I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, educational, financial, and other related matters as may be necessary for an employment decision. I hereby release employers, school, and individuals from all liability when responding to inquiries in connection with my application.

In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in discharge,

Reference Check Consent

I voluntarily consent to allow Professional Counseling Center or any of its officers, employees or agents to check my personal and work related references by contacting any person they deem to be appropriate.

I understand the questions may be about my educational background, salary history, work behavior, performance ratings and/or any relevant experience. I also give Professional Counseling Center, P.C, permission to contact not only the references I have provided, but anyone else familiar with my job performance at any of the companies listed in my work history or personal acquaintances of mine you may know.

The provided listed references are hereby released from all liability for providing such information by signing below.

Authorization and Consent for Pre-Employment Screening Form

In connection with my application for employment at Professional Counseling Center, I hereby authorize the Employer and any agent it authorizes to perform a pre-employment background screening check (including future screenings for retention, promotion or re-assignment if applicable unless revoked in writing). I understand and agree to the following:

I understand that the employer may obtain information about me having a bearing on job performance, and may include information from public and private sources, public records, courts, schools, former employers and references concerning my driving record, court records, worker's compensation record, education, credentials, identity and previous employment.

I understand that personal information and fingerprints submitted by live scan are used to search against criminal identification records from both the Michigan State Police (MSP) and Federal Bureau of Investigation (FBI), National and local Sex Offender registries and Central Registry Check (DHS). I hereby authorize the release of any records to the person or agency listed above.

I authorize and release people, companies, references, current and former employers, schools, municipal, county, state and federal agencies and courts, to provide all information that is requested to the employer or its authorized agents. I further release and hold harmless all of the above, including the employer, to the full extent permitted by law, from any liability or claims arising from retrieving and reporting of information concerning me.

I agree a copy or fax of this document shall be valid as the original.

By signing my name in the box below, I verify and affirm that all the information on this form and all information on my resume and application as well as all information given during any interview is true and correct. Any false information or material omission is grounds to terminate the hiring process, or to terminate employment at any time if it has started.