Employment Application

Authorization to Make Contact

I, the undersigned applicant, hereby authorize Urologic-Specialists to contact all former and/or present employers, references, and any other agency, business, and/or individual that Urologic-Specialists deems necessary to contact during its investigation of my background. I also agree to indemnify and hold harmless Urologic-Specialists for any and all disclosures made to or by it in good faith relating to my employment.

Certification

I hereby affirm, under penalties of perjury, that all statements and representations made by me in this application are true to the best of my knowledge and belief. I hereby authorize Urologic-Specialists to investigate any and all statements contained in this application and specifically direct and authorize all previous employers to release relevant information about me to Urologic-Specialists, and further, I agree to indemnify and hold Urologic-Specialists harmless as to any and all disclosure made to it or by it in good faith relating to my employment. I understand that as part of its investigation into my background, Urologic-Specialists may conduct a criminal history check and that any offer of employment may be dependent upon satisfactory completion of a drug screen and satisfactory references. I further understand and agree that the position I am applying for is for no definite duration and may be terminated by me or by Urologic-Specialists at any time without cause. Any and all answers are subject to verification by Urologic-Specialists at any time before or after employment. Any false, misleading, or incomplete answer will be cause for immediate disqualification or for immediate termination in the event of employment.

Urologic-Specialists is an Equal Opportunity Employer and does not discriminate on the basis of race, religion, color, sex (including pregnancy, gender identity, and sexual orientation), age, national origin, disability, genetic information (including family medical history), participation in military service, or any other protected status.