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

I agree to: a pre-placement health evaluation including drug/alcohol testing; submitting proof of citizenship or immigration status; meeting attendance and performance requirements; conforming to company policies; and testing for illicit substances per company policy.

I certify all facts and statements are true. Falsified statements will result in rejection of this application or, if hired, immediate termination. I understand employment is "at will" and may be terminated by either party at any time. I consent to an investigative consumer report which may include information from former employers, law enforcement, credit agencies, and public records.