Before sending this application, please read
the disclaimer below.
I hereby certify that I personally completed
this form, and that the information is true, correct, and
complete, to the best of my knowledge. I authorize St. Henry
Tile Co., Inc. to obtain information relating to my past or
present work history in accordance with state and federal laws.
Furthermore, I give my express consent for St. Henry Tile Co.,
Inc., any previous employer, their agent, or Medical Review
Officer or their agent to release information concerning any of
my past controlled substance tests. I release all persons from
any liability or damages. I authorize release of any
information, including all information related to my alcohol and
controlled substances testing and training records, by any
former employers and hold them harmless of any liability from
release of said information.
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