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Please list two personal references (non-family) who support your desire to serve as a Hospice volunteer.

I certify that the answers given herein are true and complete to the best of my knowledge. I understand that any misrepresentations, omissions of facts, or incomplete answers in any application document will disqualify me from further consideration. I further understand that any misrepresentations or omissions of facts in any application document will result in my dismisal without prior notice regardless of when such misrepresentation or omission is discovered. I hereby authorize Midwest Hospice to contact any company or individual it deems appropriate to investigate my employment history, character, and qualifications. I give my full and complete consent to those individuals/entities to reveal any and all information they wish as a result of this investigation. In addition, I hereby agree not to file or pursue any complaints, claims, or legal actions of any kind against any organization or individual that provides work related information about me to Midwest Hospice or its agents in accordance with the terms and intent of this release. I also agree not to file or pursue any complaints, claims, or legal actions against Midwest Hospice or any of its employees, representatives, or agents arising out of their efforts to obtain work-related information about me. Midwest Hospice does not unlawfully discriminate and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for volunteering on a basis prohibited by local, state or federal law.