“Help us to stay online by your kind donation.
Every penny will help.”
TO WHOM IT MAY CONCERN
For the limited purpose of consideration of employment with [Name], I, the undersigned individual, asserting that I am over the age of majority do authorize the following medical examination: [Enumerate].
I realise that the medical examination will be conducted for the benefit of my prospective employer and will be included as a part of my prospective employer's determination whether to extend an offer of employment to me.
I release both the medical professional who will conduct such tests and [Name] from all liability for diagnosis and treatment. I voluntarily authorize this consent without limitation or uncertainty.
Name of Undersigned
This Section for Notary:
STATE OF -------)
) ss: [Date]
COUNTY OF ------)
On [Date] before me, [Name of Notary], notary, personally appeared [Name of Person(s) Involved], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal.
[Name of Notary Public]
My commission expires: [date]