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I HEREBY AUTHORIZE MARYGOLDEN HOUSE INC. TO REQUEST AND RECIEVE FROM ALL PRIOR EMPLOYERS WITHIN ONE YEAR OF THE DATE OF THIS APPLICATION ANY AND ALL PERTINENT INFORMATION CONCERNING MY PRIOR EMPLOYMENT AND ITS TERMINATION, INCLUDING THE REASONS FOR SUCH TERMINATIONS. I hereby state that all the information I have provided is true and complete statement of the facts. False statements contained in this application are immediate cause for dismissal from registrant caregiver status. I further give permisison for this agency to verify all schooling and references.