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BACKGROUND INFORMATION

Background Information Cont'd

Job Interest

EDUCATION, TRAINING AND PROFESSIONAL LICENSURE/REGISTRY/CERTIFICATION

Graduate or Professional School

Trade of Business School

Is there anything else you'd like to tell us about your college education?

Employment Record

Starting with your current or most recent, list all employers past and present. Include self-employment and summer and part-time jobs. If more space is required, please continue on a separate sheet. You may attach a resume, but you must also complete this Section and MCL, may verify all information disclosed in this Section.

Additional Employers

Additional Employers

Additional Job-Related Experience

References

Reference 2

Reference 3

STATEMENT CONCERNING SCREENING FOR DRUG AND ALCOHOL ABUSE

I understand that, if I am otherwise qualified for employment, MCL may extend to me a conditional offer of employment and such offer will be contingent upon my successfully passing a substance abuse screening test. With regard to certain positions, the screening test for drugs and alcohol may be part of a more comprehensive health screening examination.

I also understand that I may not be hired if I test positive for alcohol or an illegal drug, refuse to provide a specimen on the date and time required, refuse to consent to testing on the date and time required or provide a false or tampered specimen.

I further understand that, if I become employed by MCL. I will be subject to MCL’s Drug and Alcohol Policy. Included among the provisions of the Drug and Alcohol Policy are requirements for drug and/or alcohol testing whenever MCL has reason to believe that an individual may be under the influence of drugs and/or alcohol while on duty or on the premises of MCL, following an accident, and as part of periodic testing of all MCL employees conducted at MCL’s discretion. Further, the refusal to provide a specimen on the date and time required may result in discharge and constitutes willful misconduct.

You may obtain additional information from MCL’s Drug and Alcohol Policy or from a Human Resources Representative.

APPLICANT’S CERTIFICATION

Please read carefully and, if you need clarification, ask questions before signing below.

I certify that the answers given by me to the foregoing questions and the statements made by me in this Application are correct and complete. I understand that, if I become employed, any misrepresentation or omission of fact in this Application may result in my discharge from employment. I understand that I may be subject to other requirements as part of the application process, including tests of aptitude, skill, or personality.

I authorize MCL as part of its evaluation of my suitability for employment, to verify all education, training and professional licensure/certification/registry claimed by me and to secure from my previous employers and references information concerning my professional accomplishments, reviews, disciplinary action, skills, character and ability. I further authorize MCL to secure from the appropriate sources information concerning criminal convictions and agree to execute the written authorizations necessary for MCL to obtain access to and copies of records pertaining to the aforementioned information. If I am hired, I agree to immediately notify MCL if I am convicted of a felony or any crime involving theft or dishonesty and I further authorize the procurement of criminal record checks throughout my employment with MCL. For these purposes, a photocopy of my signature which appears below shall serve in the same capacity as an original.

In compliance with the federal Immigration Reform and Control Act, I agree, if hired, to provide within three (3) business days from the date my employment begins proof of my identity and eligibility for employment in the United States. I understand that this Application is not a contract for employment and that, if I am employed, both MCL, and I each retain the right to terminate my employment for any or no reason with or without notice at any time. I also understand that no representative of MCL other than its President or a duly authorized representative of the President and then, only in writing, has the authority to enter into any agreement for employment for any specific time or to make any agreement contrary to the foregoing.

Further, I understand that, if I am employed, all materials, equipment and space allocated to me for the discharge of my duties may be inspected as deemed necessary by MCL at its sole discretion.