**Job Location:** Santa Fe **LICENSES & SPECIAL SKILLS**

List the number, expiration date, and State of issuance of any professional or occupational license you hold. Specific Duties Specific Duties Briefly describe your specific duties **CERTIFICATE OF APPLICANT**

Permission is hereby granted to HME Specialists to conduct any necessary and reasonable investigation with respect to statements and other information in this application. I release HME Specialists, my former employers and personal references from any liability for damage caused by giving and receiving information or opinions as to my employment and character. I agree to furnish any other information required of me related to my employment. I also understand and agree that any false statements or any material misrepresentation of the information referred to above will be sufficient grounds for my separation. I understand the requirements and essential functions of the job(s) and certify that I am able to perform those job duties and functions. I have a genuine interest to be employed and no other purpose in submitting this application. I understand that this employment application will remain active for 120 calendar days, and that upon expiration of this application, to continue to be considered for employment, I must complete a new application.