Berkley Southeast Insurance Group

I affirm that the information I have provided in this application is true to the best of my knowledge, information and belief, and I have not knowingly withheld any information requested. I understand that withholding or misstating any information requested in this application is grounds for rejection of my application, and that providing false or misleading information in this application is grounds for discharge. I authorize the company to verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release the Gwinnett Chamber, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such inquiry or disclosure. I understand that if offered employment with the Gwinnett Chamber of Commerce, all employment is contingent on the successful completion of a drug screen and background check.