Volunteer's
Certification, agreement, and notice. (Please read carefully)
I certify that all information in this application is true and complete. I understand that any false information
or omission may disqualify me from further consideration for volunteer service and may result in my dismissal, if
discovered at a later date. I understand that Pomona Valley Hospital Medical Center requires certain information
both personal and professional from me to evaluate my qualifications for volunteer service. I understand that in
review of my application, a background investigation may be conducted. I authorize and realease all past and
present emplyers personal references,and any other organization to answer all questions asked concerning my
previous employment and/or volunteer record, ability, character, emotional background, military services, criminal,
and if applicable, driving history.
In consideration of my application for volunteer service, I authoriz Pomona Valley Hospital Medical Center and
all associated entities, to conduct an investigation which may include, but is not limited to, the performance of
medical examinations, drug screening, reference verification, driving history, military service, and criminal
background check which may be in the files of any federal, state, or local criminal justice agency. I understand
that any information requested is for the sole purpose of gathering information accurately for use in the
above-mentioned volunteer and background investigation.