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EEO Voluntary Self-Identification

Disclaimer and Signature

I certify that the information provided herein and on any other attached relevant documentation is true and complete to the best of my knowledge. I authorize PhyAmerica Government Services Inc. to verify any information I have provided on this application or in other materials (such as a personal resume) provided by myself and understand that any misrepresentation or omission will eliminate me from consideration for employment or will be grounds for terminating my employment once hired.

I authorize the release and investigation of any and all information, including credit-related information, concerning my qualifications or which may be considered necessary in arriving at an employment decision, and waive any and all claims for liability arising out of any investigation. I understand that drug testing is a condition of my employment with the Company. I agree to save and hold harmless, release and forever discharge the Company, its officers, directors, employees and agents from any and all suits or causes of action arising out of my taking a substance abuse screening test.

I understand that this application will remain active for a period of no longer than ninety (90) days from the date of submission. I understand that if I wish to be considered for employment beyond this time period, I will need to reapply. I also understand that employment with the Company is “at will” meaning that either the Company or the employee may terminate the employment relationship at any time for any reason. In the absence of a written agreement approved by the Company, this at-will agreement may not be changed by any policy of the Company or by any promise, express or implied, by any officer or agent.

I hereby authorize the Company to undertake any investigation it deems necessary in considering my application for employment, or if hired, my continued employment. I expressly authorize and unconditionally release any person from all liability relating to any such request for information or for any information provided.

I understand that the Company is an affirmative action, equal opportunity employer and that employment with the Company. is based solely on my qualifications and experience related to the position I am applying for. Likewise I understand that this application is not an offer of employment or a contract for employment.