|I hereby certify that the information provided herein is correct to the best of my knowledge and understand that|
falsification of this information is grounds for refusal to hire or, if hired, dismissal.
I hereby authorize any of the persons or organizations listed in this form to give all information concerning my
previous employment, education, or any other information they might have, personal or otherwise, with regard to
any of the subjects covered by this form, and release all such parties, agencies and entities from all liability
that may result from furnishing such information to you. I authorize you to request and receive such information.
In consideration for my employment and my being considered for employment by DG&M, Inc., I agree to adhere to
the rules and regulations of the company and hereby acknowledge that our company may change these rules and
regulations at any time, at the company's sole option and without any prior notice. In addition, I understand and
agree that employment with DG&M, Inc. will be "at will" and acknowledge that my employment may be terminated,
and any offer of employment, if such is made, may be withdrawn, with or without prior notice, at any time,
at the option of either the company or myself.
I consent to a drug test, either prior to commencement of employment or after I have become employed or during
my course of employment as deemed necessary by the employer.