Applicant Consent to Release Liability and Reference Information
I, _____________________________ (print name), in consideration of employment with the Hopi Tribe, hereby authorize the
Hopi Tribe to perform background checks, reference checks and employment verifications on me. These checks may include, but
are not limited to discussions with: supervisors, coworkers, business associates, or any other party who the Hopi Tribe may use
sole discretion believes may have relevant job related information regarding my suitability for employment. The Hopi Tribe may
also verify information that I have provided on the completed employment application and/or resume.
I agree not to assert any demands, damages, claims, suits or causes of action of any kind against the Hopi Tribe, its offenders,
employees, agents or the organizations, officers, employees, and agents contacted arising out of the Hopi Tribe performing a
good faith effort to check my employment references.
I acknowledge that my failure to authorize the Hopi Tribe to check my references shall disqualify me from consideration from
employment. I acknowledge, the Hopi Tribe has made no representation that employment will be offered to me upon the
completion of reference checks.
I understand the position I am applying for may require a satisfactory background check.
I acknowledge that employment at the Hopi Tribe may be conditioned upon satisfactory completion of an employment medical
assessment, which may include a screening test for the presence of controlled substances. Continued employment would be
continued upon the successful completion of any additional medical assessments that may be reasonably requested by the Hopi
Tribe. Upon reasonable suspicion, the Hopi Tribe may require that I participate in further urinalysis screening tests for the
presence of controlled substances.
I also acknowledge that if the position requires driving in the course of work, I understand that I will be required to possess a
current and valid driver's license and understand that I will be required to provide a copy of my driving record.
I hereby verify, under the penalty of perjury, the information contained in this application is true, correct, and complete to the
best of my knowledge and belief. I am aware that, should an investigation at any time disclose misrepresentation or falsification,
my application will be rejected, and I may be dismissed from employment and disqualified from future employment with the
A photocopy or facsimile (fax) of this form that shows my signature shall be as valid as the original.
I UNDERSTAND THAT THIS APPLICATION IS VALID ONLY FOR THE POSITION APPLIED.
Applicant's Signature Date