I certify that the information provided on this application is truthful and accurate. I understand that
providing false or misleading information will be the basis for rejection of my application, or if
employment commences, immediate termination.

I authorize 7TH & Madison Extensions of Empowerment to contact former employers and
educational organizations regarding my employment and education. I authorize my former
employers and educational organizations to fully and freely communicate information regarding my
previous employment, attendance, and grades. I authorize those persons designated as references
to fully and freely communicate information regarding my previous employment and education.

If an employment relationship is created, I understand that unless I am offered a specific written
contract of employment signed on behalf of the organization by its Director, the employment
relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, and
either I or my employer will be able to terminate the employment relationship at any time and
without cause. With appropriate notice, I will have the full and complete discretion to end the
employment relationship when I choose and for reasons of my choice. Similarly, my employer will
have the right. Moreover, no agent, representative, or employee of 7TH & Madison Extensions of
Empowerment, except in a specific written contract of employment signed on behalf of the
organization by its Director, has the power to alter or vary the voluntary nature of the employment
relationship.

I HAVE CAREFULLY READ THE ABOVE CERTIFICATION AND I UNDERSTAND
AND AGREE TO ITS TERMS.