APPLICANT: Please read the following carefully before signing:
I hereby voluntarily and without duress agree to all of the following terms. Any term listed below not in compliance with applicable laws will be void, but in no way affects any other term.
I declare and affirm that the information provided on this Application and any other materials submitted to support this application is correct and complete. I understand and agree that any false statements or materials omissions may disqualify me from further consideration for an externship and may be considered justification for dismissal if discovered at a later date. I further affirm that I am completing this Application because I am sincerely interested in completing an externship with CTOA, PLLC and not for any other purpose.
In consideration of my being considered for an externship, I authorize the Association to investigate at its discretion, my past employment record and to make further investigation as it deems proper with respect to my experience, character, and integrity and to verify the statements and answers contained herein. I agree to cooperate in such investigation, and I release from all liability or responsibility of the Association, and its affiliates, employees and agents and all other persons or enemies requesting or supplying information for investigation. Except as otherwise protected by law or regulation, the information contained in the Application is not confidential and may be used or reported by this practice.
I also agree never to disclose or to use for my personal benefit any confidential information of CTOA, PLLC or its patients. If offered an externship, I agree to abide by the safety rules and other policies of the Association.
I have carefully read the above and fully understand its meaning and effect.