Job Application

Professional References

Please give the names of three persons not related to you, whom you have known professionally at least three years.

Professional Reference 3

Employment History

List your past three employers, starting with your current or most recent employer

Yes

No

Second Employer

Yes

No

Third Employer

Yes

No

Application's Statement

I understand that if I am hired, my employment may be terminated with or without cause or notice, at any time, at either my option or that of Kirkhaven. I understand that no management representative has any authority to enter into any agreement for continuing employment for any specific period of time or which is contrary to the foregoing and that any such agreement must be in writing signed by the Company President. I give Kirkhaven permission to contact all or any of my previous employers and references and authorize them to disclose any information Kirkhaven may request in the course of its investigation of this application for employment, and I hereby release Kirkhaven and such references and prior employers from any and all liability with respect to such disclosures. After a tentative offer of employment has been made, if requested by Kirkhaven, I agree to take a job-related medical examination at no personal expense and authorize the examining physician to disclose the findings to Kirkhaven. I understand that any offer of employment is conditioned upon receipt of satisfactory references and satisfactory completion of any such job-related medical examination. I also understand that I may be requested now or at any subsequent time during my employment with Kirkhaven to submit to drug and/or alcohol tests, at Kirkhaven’s expense. I understand that if I refuse to take the test, my employment may be terminated immediately. I have provided truthful and complete responses to all inquiries in the application and authorize Kirkhaven to investigate all statements contained in the application. I understand that the discovery of any falsification or omission constitutes a ground for immediate dismissal or refusal to hire. If employed, I will abide by Kirkhaven’s rules and regulations, which I understand are subject to change by Kirkhaven.