I hereby affirm that all information on this form is true and correct, with no omissions, false information, or misrepresentation of facts. I authorize any physician, medical facility, law enforcement agency, administrator, state agency, institution, information service bureau, insurance company, or employer contacted by Mid America Service Solutions to furnish or verify workers compensation information and medical records.

Please read carefully: Applicant agrees to the following conditions of employment: a pre-placement health evaluation including possible laboratory testing for drug or alcohol use; submitting proof of citizenship or immigration status upon employment; completing surety bond application if required; meeting attendance and performance requirements; conforming to company policies and procedures; and testing for illicit substances per company policy.

Applicant understands that employment is based on specific project needs and may be terminated or require layoff as project workforce needs dictate.

I certify that all facts and statements in this application are true and complete to the best of my knowledge. I understand that any falsified statements or omissions will result in my application being rejected or, if hired, in my termination.

I understand that any employment relationship with Mid America Service Solutions is an "at will" nature, meaning I may resign at any time and Mid America Service Solutions may discharge me at any time with or without cause, unless otherwise defined by applicable law or collective bargaining agreement.

I consent to an investigative consumer report being prepared, which may include information from former employers, law enforcement agencies, credit agencies, and public records. My signature below releases all parties from liability for collecting this information.