I hereby certify that my answers and assertions set forth in this application are true and complete to the best of my knowledge. If I am employed, I understand that any false statements on this application shall be considered sufficient cause for my dismissal. I hereby authorize this company to investigate any aspect of my prior educational and employment history. Furthermore I understand that if I am hired, employment with this company is "at will," which means that either the company or I can terminate my employment for any reason not prohibited by state or federal law.

I have applied for employment with Country Partners Cooperative and have provide information about my previous employment. By checking “I agree” below, I authorize my former or current employers and references to release the contents of my employment record with their organizations and to provide any additional information that may be necessary for my application for employment to Country Partners Cooperative, whether the information is positive or negative. I authorize Country Partners Cooperative to investigate all statements made in my application for employment and to obtain any and all information concerning my former / current employment. This includes my job performance appraisals / evaluations, wage history, disciplinary action(s) if any, and all other matters pertaining to my employment history. I knowingly and voluntarily release all former and current employers, references and Country Partners Cooperative from any and all liability arising from their giving or receiving information about my employment history, my academic credentials or qualifications, and my suitability for employment with Country Partners Cooperative. This form may be photocopied or reproduced as a facsimile, and these copies will be as effective as a release or consent as the original which I sign. This consent will be valid for no longer than six (6) months.