Miscellaneous Information

Do you have any allergies? ________  If so, to what? __________________________

Are you able to lift at least 50 pounds at least 3 feet off the ground? ______________

What is your salary expectation? ____________ In one year? ___________________

Do you have any pets? ___________ If so, please elaborate ____________________

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In consideration of my employment, I agree to conform to the rules and regulations of Stow Kent Animal Hospital, Inc.  I further agree that my employment can be terminated with or without cause or notice at any time at the option of the Corporation or myself.  I understand that no corporate official or representative other than an officer of the company has any authority to enter into an employment agreement for a specific period of time or make any agreement contrary to the foregoing.  I have read this paragraph and I understand the words and terms contained in this paragraph.

It is my understanding that this application for employment will remain valid for 90 days from the date of this application.  For future consideration beyond 90 days, a new application must be completed.

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Applicant's Signature

AUTHORIZATION FOR RELEASE OF INFORMATION

As an applicant for a position with Stow Kent Animal Hospital, I have been asked to furnish information for use in reviewing my background and qualifications.  In this connection, I hereby authorize personnel from Stow Kent Animal Hospital to investigate my past and present work, character, education, military records, police records as to ascertain any and all information that may be pertinent to my employment qualifications.

I agree to cooperate in such investigation and release from all liability or responsibility all persons and corporations requested to supplying such information.

This authorization is valid for 3 (three) months from the date of my signature below.  You may retain a copy of my release for you files.

I hereby release for liability Stow Kent Animal Hospital, Inc. and its representatives for seeking such information and all other persons or organizations for furnishing such information.

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Name of applicant     Social security number

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Signature of applicantDate

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Interviewer witness    Date

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