I, the undersigned, hereby permit the above noted employer(s) to release any and all information relating to my dates of employment, performance, attendance, etc. to Legal Medical Staffing Services, Inc.

I further agree to immediately notify LMS should a client, representative of client, or referral of client, or any individual sharing space in client office make a direct offer of Temporary, Part-Time or Full-Time employment to me while on a temporary assignment or interview. I understand my obligation to notify LMS extends for a period of twelve months from the last temporary assignment date or interview referral date. It is further agreed that I will advise client of their obligation to contact LMS to review client's financial responsibility. In the event I do not contact LMS regarding the above, I acknowledge my responsibility to pay LMS the placement fee. Additionally, should I accept a Part-Time or Full-Time position with an LMS client to which I was referred by LMS and subsequently withdraw that acceptance as a result of a counteroffer or other reason, I acknowledge my responsibility to pay LMS the placement fee.

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SIGNATURE (Upon interview date, we will have you review your online application and sign.)

LMS IS AN EQUAL OPPORTUNITY EMPLOYER. QUALIFIED APPLICANTS ARE CONSIDERED FOR EMPLOYMENT WITHOUT REGARD TO AGE, RACE, COLOR, RELIGION, SEX, MARITAL STATUS, NATIONAL ORIGIN, HANDICAP OR VETERAN STATUS.