Shift choices are as follows. Please check your first and second choice.

(List last or Present Position First)

I voluntarily give Centerville Community Betterment, Inc. the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release for all liability or responsibility all persons, companies, or corporations supplying such information. I consent to take the pre-employment physical examination and such future physical examinations as may be required by this institution at such times and places as the institution share designate. I understand that I will be required to follow the personnel policies and rules of the facility and those infractions of said rules may lead to dismissal. I also understand that my employment may be terminated for any misinformation or omission of fact appearing on this application form. I further understand that this facility follows the “fair employment practice code” and there is no discrimination in the hiring of individuals based on sex, race, religion, age or physical or mental handicap unrelated to ability to perform the work required. I understand that if I am employed it will be on a probationary trail basis for a period of 60 days. Upon my termination I authorize the release of reference information on my work.