I hereby authorize any prior employers to provide such information concerning my employment with them as may be requested, and also authorize the Registrar/Placement Office of all educational institutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my licensure status and my licensure history.
I agree that I will settle any and all claims, disputes or controversies arising out of or relating to my application for employment, employment or termination of employment with the employer exclusively by final and binding arbitration and before a neutral Arbitrator and in accordance with the rules and procedures for employment disputes adopted by the employer. Such claims shall include those that could be brought in a court of law under any applicable federal, state or local statutory or common law, such as the Age Discrimination in Employment Act, Title VII of the Civil Rights Act of 1964, as amended, including the amendments of the Civil Rights Act of 1991, the Americans with Disabilities Act, the Family and Medical Leave Act, state civil rights acts, the law of contract and the law of tort.
In consideration of my application, I authorize Madison County Memorial Hospital by and through State of Iowa to verify all data given by me on application, related papers or oral interviews. I understand a thorough investigation may be conducted which may include but not be limited to criminal history, motor vehicle driving record, education verification, employment history, credit report and personal history. I hereby authorize employers, agencies, personal references and other persons with whom I am acquainted to answer all questions and release all information concerning my employment record, character, reputation, ability, education, military service, credit history and other applicable reports. Furthermore, I release all agencies, bureaus, employers, information service organizations, and individuals or companies named above from all liabilities or damages that might result from information provided in good faith. I state that the information provided by me on my application is accurate and I agree that is any information is found to be false at any time, my application may be discarded or my employment terminated. I understand that the information requested below regarding sex and date-of-birth are for the sole purpose of gathering the above information accurately and will not be used to discriminate against me in violation of the law. * A facsimile (FAX) or photocopy of this authorization shall be as valid as the original.
* State of Iowa fully complies with the Fair Credit Reporting Act and the ADA.