Read Carefully before signing and dating. <br />I certify that all information on this application is correct. I authorize any agent or employee of LBHS to verify this information and to release it to anyone who may consider me for appointment. I  understand that intentionally providing false information on this form or attachments is a violation of state law. I also understand that applications submitted electronically, via e-mail or similar media are not valid unless I acknowledge below and such action shall constitute an electronic signature.<br /><br />Legacy Behavioral Health Services is an Equal Employment Opportunity Employer .