If YES, when?
(No Former employers or Relatives)
PLEASE READ AND SIGN BELOW
The facts set forth in my application for employment are true and complete. I understand that if employed, any false statement on this application may result in my dismissal. I understand that my social security number will be checked against both the Federal and State’s Medicaid exclusion databases to verify if I’ve been excluded/terminated from a Medicaid Program. I further understand that this application is not and is not intended to be a contract of employment, nor does this application obligate the employer in any way if the employer decides to employ me. No one other than an officer of the company has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing and then only in writing and signed by an officer.