(970) 207 - 1005
540 W 66th St B1
Loveland, CO 80538
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I affirm that the information I have provided in this application is true to the best of my knowledge, information, and belief, and I have not knowingly withheld any information requested. I understand that withholding or mistaking any information requested in this application is grounds for rejection of my application, and that providing false or misleading information in this application is ground for discharge.

I authorize the company to verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with the without giving me prior notice of such discourse. In addition, I release the company, my former employers and all other persons and entities, form any and all claims, demands or liabilities arising out of or in any way related to inquiry or disclosure.