Indicate below all current and past employers. Please account for any gaps or periods of unemployment.

Please list three individuals below, who have knowledge of your work performance during the last five years.

Our agency prohibits discrimination against and harassment of any employee or any applicant for employment because of race, color, national or ethnic origin, age, religion, disability, sex, sexual orientation, gender identity and expression, veteran status or any other characteristic protected under applicable federal, state or local laws.

I hereby certify that the foregoing answers are true and complete to the best of my knowledge. I understand that any misrepresentation, falsification or omission of facts on this application or other forms that I may submit in connection with my application for employment, will be sufficient cause not to hire or cause to terminate my employment whenever discovered. I authorize the authorities of [Company] (the “Agency”) to investigate references and all other statements made on this application and authorize any entity or individual to provide information related to this application including but not limited to: employment records, including attendance records, work performance, disciplinary reports, letters of reprimand, involuntary termination information and other disciplinary action, without giving me notice of such disclosure. I authorize the Agency to make inquiries of courts and law enforcement agencies for records of prior convictions. I acknowledge that I am not obligated to disclose sealed or expunged records of convictions or arrests, and I understand that the Agency will not consider such information in making any employment decision. I agree to cooperate fully with the Agency's background checking process, including, but not limited to executing any additional consent forms necessary to conduct background checks or drug testing. If a conditional job offer is extended, I hereby give permission to conduct a pre-employment screening, which may include background checks, drug screening and a complete physical examination. I expressly agree not to hold the Agency liable in any manner in connection with the investigations and inquiries described above. I understand that if I become employed I will abide by all Agency rules and policies. I also understand that employment with the Agency is "employment at will" and that my employment and compensation may be terminated, with or without cause, with or without notice, at any time at the option of the Agency or myself. This application is not a contract or guarantee of employment.

If offered a position with the Agency, I hereby agree to any legally permitted physical, psychological, competency, skill, drug, or medical test required by the Agency as a condition of employment.

I authorize initial and post-hire investigations into all statements and references contained in this application. Said investigation may include: OIG Exclusion List Verification, Aide Certification Verification, Vehicle Insurance Verification, Fingerprint Clearance Card Verification, Credit, Driving, Criminal background, reference checks, and other background checks.

I understand that if I accept employment with the Agency, I may be exposed to potential hazards related to the provision of homecare services within private residences or medical facilities. Such hazards include but are not limited to physical exertion related to heavy lifting, continuous motion, standing for long periods of time, and exposure to on the job chemicals such as cleaning agents and medications.

By typing my initials and my complete name below, I acknowledge that I have read and understood the policies and conditions contained herein and agree to be bound by them if employed by [Company]