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APPLICANT’S STATEMENT I certify that I have read the “Notice to Applicant” regarding the Minnesota Data Practices Act, and understand my rights as a subject of data. I authorize that a transcript may be requested where necessary to verify any education record. I hereby expressly authorize the collection, use and release of any and all information concerning me, which relates to my employment. I hereby release the City of Centerville, with which I am seeking employment, from any liability which may result from releasing information requested. I also expressly authorize the release by my present and past employers, including its agents/employees of any and all information concerning my employment with them, in any form, oral or written, and I agree to hold harmless my present and past employers from any liability whatsoever arising out of its release of information pursuant to this release. I understand that if offered a position, I must submit to and pass a drug screen and depending on the position, may be required to submit to and pass a psychological examination, a physical examination and/or a physical agility test. I hereby certify that all answers contained in this application are true and I agree and understand that any misrepresentation or omission of facts contained in this application will be grounds for disqualification for employment or in the event of employment, dismissal from employment upon discovery of the information. Failure to sign this form may result in rejection of your application. By signing this form I hereby acknowledge I have read and understood the above statements. Signature of Applicant Date