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.