I certify that the following herein provided is true and accurate and realize that falsification of any information will warrant immediate dismissal. I hereby authorize all former employers and personal references to release any and all information requested by the Putnam County Hospital. The undersigned fully understands that any offer of employment made to a job applicant at Putnam County Hospital may be contingent upon the passing of drug screen test. 

 By checking this box, I am giving my permission to verify employment and authorizing legitimacy of this information provided. 

I authorize Putnam County Hospital to conduct a background check as part of the application process.