I certify that the information submitted in this application is accurate.  I hereby grant Medical Placement Staffing Services permission to verify my employment history, financial, and credit records.  I further authorize Medical Placement Staffing Services the right to contact listed past employers for such information as may be requested for the purpose of evaluating me for possible employment.  It is understood that any false statement is sufficient reason for dismissal.

^{I Agree   I Disagree}