By signing this form, I understand that if I provide false information or willfully fail to disclose material information required by this form I will be subject to professional discipline up to and including termination and denial of employment, and any other criminal or civil penalties in accordance with state law and regulations. I hereby authorize the employer named on this form to release the requested information, and any other information permitted by law, to the entity listed below. I release, waive and discharge the employer identified on this form and the entity named below from any and all liability of any kind that may arise from the disclosure and use of the information provided on this form.