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Personal Information
Permanent Address
Present Address
Education History
High School
Trade, Business or correspondence school
Employment Desired
Former Employers
Prior Employment 1
Prior Employment 2
Prior Employment 3
General Information
Reference 1
Reference 2
Reference 3

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of my background through SLED checks and all other information provided and release Nightingale’s from all liability from any damage that may result from using such information. I also understand and agree that no representative of Nightingale’s has any authority to enter into any agreement for employment for any specific period of time or to make any agreement contrary to the foregoing, unless in writing and signed by an authorized Nightingale’s representative. This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans With Disabilities Act (ADA) and other relevant federal and state laws.