List three individuals, at least 21 years of age or older and not considered relatives or personal friends, who observed or experienced first hand your work style, habits and performance. Examples might include a coordinator of your volunteer efforts, college professor, pastor/faith community leader, or former coworker.

I certify that I have personallyt completed this application. I understand and agree that Centerline Supply may at any time seek verification of the above and further information in considering my suitability for the current, or any future, position. I hereby request and authorize anyone approached by Centerline Supply its employees and/or agents, to provide them with any and all information requested to the best of their ability. I hereby release Centerline Supply its employees and agents, and anyone providing information pursuant to a request from Centerline Supply to provide information about me, from any and all claims whatsoever which may arise as a result of the release of such information. I understand and agree that any omission, false or misleading statement may disqualify me from employment, or result in dismissal. A photographic copy of this authorization shall be as valid as the original. I understand the nature of the position for which I am applying and certify that I am able to perform its essential functions as outlined. I understand that employment is at will and Centerline Supply may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits. I understand that as a condition of mycontinued employment Centerline Supply may, form time to time, require me to submit specimens of blood, urine, and other bodily fluids for testing to determine the presence of alcohol and/or controlled substances. I understand that if offered a position with Centerline Supply, I may be required to submit to a pre-employment examination, drug screening and background check as a condition of employment. I understand results form, refusal to cooperate with, or any atempt to affect the results of these pre-employment checks may result in withdrawal of any employment offer or termination of employment.