This institution does not discriminate in hiring or any other decision based on race, color, sex, citizenship, national origin, ancestry, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. No question on this application is intended to secure information to be used for such discrimination. I am applying for employment with Star Pediatric Homecare Agency, Inc. on a voluntary basis. I was not solicited by any staff from Star Pediatric Homecare Agency, Inc to become an employee. My decision to select Star Pediatric Homecare Agency, Inc. as an employer was made by me personally. : I, hereby authorize Star Pediatric Home Care Agency to request and receive from all prior employers within a minimum one year of the date of this application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination. I consent to take the physical examination and such future physical examinations as may be required by this institution at such times and places as the institution shall designate. I understand that an offer of employment may be contingent on passing the physical examination which relates to the essential duties I would be required to perform. I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I also understand that my employment may be terminated for any misstatement or omission of fact appearing on this application form. If employed, I will be required to complete an Employment Verification Form (I-9), and within three days show satisfactory evidence of identity and eligibility for employment.