APPLICATION FOR EMPLOYMENT: AN EQUAL OPPORTUNITY EMPLOYER

Our practice does not discriminate on the basis of race, religion, national origin, color, sex, age, veteran status, disability, or any other status protected by applicable law or regulation. It is our intent that all qualified applicants be given equal opportunity and that selection decisions be based on job-related factors. Please complete entire form and print clearly.

CONSENT FOR PRE-EMPLOYMENT REFERENCE CHECK

I have applied for employment with the Waverly Animal Hospital, Boarding & Grooming (WAHBG) and have provided information about my previous employment.

I authorize WAHBG (and it's officers/employees/representative) to conduct a reference check with my present and/or previous employer(s I understand that reference information may include, but not be limited to, verbal and written inquiries or information about my employment performance, professional demeanor, rehire potential, dates of employment, salary and employment history.

My signature below authorizes my former or current employers and references to release information regarding my employment record with their organizations and to provide any additional information that may be necessary for my application for employment to WAHBG, whether the information is positive or negative. I knowingly and voluntarily release all former and current employers, references, and WAHBG from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for employment with WAHBG.

I further authorize WAHBG to obtain feedback and references from my supervisors over the course of my employment with WAHBG. I understand that subsequent and continued employment with WAHBG may be subject to this feedback. This form may be photocopied or reproduced as a facsimile, and these copies will be as effective as a release or consent as the original which I sign.

I understand that any information provided by my references will be used solely for the purpose of determining my acceptability for employment with the Company.

Irelease all of the references from any claim of liability or damages, including, but not limited to, claims for defamation, interference with contract, and negligence-which may arise or result from any truthful reference information provided by a reference pursuant to this authorization.

CONSENT FOR PRE-EMPLOYMENT, RANDOM, REASONABLE SUSPICION, OR POST-EMPLOYMENT DRUG TEST SCREEN AND RELEASE COVENANT NOT TO SUE AND INDEMNITY AGREEMENT

Ihereby CONSENT to allow a medical facility to take a specimen of my hair, urine, or blood and submit it for a

pre-employment, random, or reasonable suspicion drug test screen. I FURTHER CONSENT to allow the laboratory testing service to make the results of such screen available to the prospective or current employer, Waverly Animal Hospital, Boarding & Grooming.

In consideration for such services being rendered on my behalf, I hereby RELEASE the laboratory testing service, its officers, agents, and employees, from any and all claims which I might otherwise have due to such results being made so available. I hereby CONSENT NOT TO FILE ANY ACTION at law or in equity against Waverly Animal Hospital, Boarding & Grooming, the laboratory testing service, their respective officers, agents or employees in connection with the results of such screen being made so available, and I hereby agree to INDEMNIFY and SAVE HARMLESS Waverly Animal Hospital, Boarding & Grooming, the laboratory testing service, their respective officers, agents, and employees from all damages, expenses, reasonable attorney's fees, and costs of court which they or any of them may suffer or incur, jointly or severally, due to the results of such screen being made so available.

I certify that all information I have provided in this application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal characteristics and mode of living. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation.

I UNDERSTAND THAT THIS APPLICATION, VERBAL STATEMENTS BY MANAGEMENT, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE AN EXPRESS OR IMPLIED CONTRACT OF EMPLOYMENT OR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. ONLY THE PRACTICE MANAGER OR OWNER HAS THE AUTHORITY TO ENTER INTO AN AGREEMENT OF EMPLOYMENT FOR ANY SPECIFIED PERIOD AND SUCH AGREEMENT MUST BE IN WRITING, SIGNED BY SUCH PERSON AND THE EMPLOYEE EMPLOYED. I UNDERSTAND THAT I MAY BE HIRED AT THE WILL OF THE EMPLOYER AND AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT REASON AND WITH OR WITHOUT NOTICE.

I have read, understand, and by my signature consent to these statements, on this date: