DISCLAIMER AND ELECTRONIC SIGNATURE

By submitting this form, I hereby authorize Dental and Medical Staffing Inc. to make such investigations and inquiries into my employment, educational history and other related matters, as may be necessary in arriving at an employment decision. I HEREBY release employers, schools, and other persons from all liability in responding to inquiries connected with my application and for employment and I specifically authorize the release of information by any schools, individuals, services, and other entities. I HEREBY AFFIRM: That all information given by me on the pre-employment application and this employee data and work history card is true and complete. If my answers are false or misleading, you have the right to dismiss me immediately. If selected for employment, I agree to provide documentation showing I am authorized to work in the United States of America. You may contact my former employers for references and release the information herein to your clients and insurance company. In the event of an "on the job" injury, I will submit to a post accident drug test. I will notify you when the assignment is ending and my availability for work.

IF I DO NOT NOTIFY DMSI OF THIS INFORMATION THE ASSUMPTION MADE BY DMSI IS:
I AM NO LONGER AVAILABLE FOR WORK AND THEREFORE QUIT DMSI.

SKILLS CHECKLIST - select all that apply

I HEREBY AFFIRM: That all information given by me on this Skills Check List is true and complete. If my answers are false or misleading, you have the right to dismiss me immediately.