Job Application Form

Career Application

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Date*

MM slash DD slash YYYY

Job Type*

Name*

First Middle Last

Phone*

Email*

Social Security Number*

Address*

Street Address Address Line 2 City State ZIP Code

Driver License OR State ID*

State ID issued*

Date of Birth*

MM slash DD slash YYYY

Years at this address?

Job Location Applying for*

State of Pennsylvania

State of New Jersey

Means of transportation?*

I am willing to travel*

Are you at least 18 yrs of age?*

Date available to start work:*

MM slash DD slash YYYY

Are you a United States citizen?*

Are you authorized to work in the U.S.?*

Have you ever worked for this company?*

Are you vaccinated?*

Can you provide Proof of vaccination?*

If So When?

Desired Hourly Rate?*

Position Applied for*

I Can lift?*

High School:*

College Degree*

I have experience in the following*

I am Ok with a smoker

I am ok with Cats

I don't like animals

I am NOT Ok with pets

I am NOT OK with Client Smoking

I have Gait Belt Experience

I have Hoyer Lift Experience

I am allergic to cats

I am allergic to Dogs

I am allergic to pets

I don't like animals

I Don't Like being around Dogs

I Don't Like being around Cats

I have Dementia Experience

I have Hospice Experience

I have Incontinence Experience

I have an Insured Automobile

Previous Employment Company 1

Previous Company*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Supervisor Name*

First Last

Starting Salary*

Date Started At This Company*

MM slash DD slash YYYY

Date Ended At This Company

MM slash DD slash YYYY

Responsibilities*

Reason for Leaving*

May we contact your previous supervisor for a reference?*

Previous Employment Company 2

Previous Company*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Supervisor Name*

First Last

Starting Salary*

Date Started At This Company?*

MM slash DD slash YYYY

Date Ended At This Company?

MM slash DD slash YYYY

Responsibilities*

Reason for Leaving*

May we contact your previous supervisor for a reference?*

Emergency Contact

Name*

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Relationship*

Military

Were you Ever in the Military?*

If so What Branch and Where?

Professional References 1

I hereby request and authorize the agency to request and receive from all prior employers within one year of the date of application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination. I Agree to hold harmless these persons of organization, their offices, Directors Employees and Agents, owners, of Liability, Claims, damages or demands of any nature arising from or related to the investigation of the information contained in my applications.

Applicant Name*

First Last

Company Name*

Professional Reference Name*

First Last

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position Worked*

Reference Relationship*

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Answer key for Office staff

Poor, Average, Good, Excellent

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Quality of Work

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Attendance

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Punctuality

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Dependability

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Competency

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Cooperation

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Telephone Verification Documentation

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Date of Call

MM slash DD slash YYYY

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Agency Representative

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Title of Agency Representative

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Person Contacted

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Notes

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Signature of Agency Representative

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Date

MM slash DD slash YYYY

Professional References 2

Applicant Name

First Last

Company Name*

Professional Reference Name*

First Last

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Position Worked*

Reference Relationship*

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Answer key for Office staff

Poor, Average, Good, Excellent

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Quality of Work

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Attendance

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Punctuality

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Dependability

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Competency

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Cooperation

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Telephone Verification Documentation

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Date of Call

MM slash DD slash YYYY

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Agency Representative

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Title of Agency Representative

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Person Contacted

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Untitled

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Signature of Agency Representative

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Date

MM slash DD slash YYYY

Personnel File Job Acceptance

Please Read Information Below and sign below.

CONFIDENTIALITY OF PROTECTED HEALTH INFORMATION

It is both the Agency's and the employee's responsibility to ensure that every patient's health information is protected at all times. By signing below you are indicating the acknowledgement of HIPAA and understand that a thorough orientation of the agency's policy regarding patient's Protected Health Information will be provided to you upon hire. I understand that I may be handling Protected Health Information. I further understand that there are specific guidelines associated for use and disclosure of Protected Health Information. The agency has sanctions and fines for all individuals failing to comply with HIPAA Rule and Regulations. I will protect all Electronic Records including passwords as outlined in the HIPAA manual.

PROTECTION OF HEALTH INFORMATION

There are specific guidelines to ensure patient's Protected Health Information is kept private. I understand that my employment with the agency involves handling Protected Health Information. I will ensure patient's records are protected by enforcing the following measures: Patient Protected Health Information will be transported in a protected travel chart when traveling. When transmitting and receiving a fax involving Protected Health Information, I will ensure that it is conducted in a private area. Patient Protected Health Information will be returned to the agency upon acknowledgement of the patient being discharged. I pledge to make every effort to keep patient's Protected Health Information protected at all times.

HIPAA CONFIDENTIALITY AGREEMENT

EMPLOYEE CONFIDENTIALITY AGREEMENT of PATIENT HEALTH INFORMATION AND PERSONAL INFORMATION in accordance with HIPAA REGULATIONS. For good consideration and as an inducement for Infinity Health Care Services, LLC, to employ Applicants (employee), the undersigned Employee hereby agrees not to directly or indirectly use, manipulate or copy compete any patient health information (PHI), to include personal health information or personal contact information (address, phone, email address, etc.) with the business of the Agency and its successors and assigns during the period of employment. Misuse of PHI or personal contact information will result in termination and report with action to HIPAA federal agencies. Fines related to civil and criminal offences for gross misconduct with the above information are the direct responsibility of said employee. The Employee acknowledges that the Agency shall or may in reliance of this agreement provide Employee access to trade secrets, customers and other confidential data and good will. Employee agrees to retain said information as confidential and not to use said information on his or her own behalf or disclose same to any third party or for their own personal or monetary gain. The Employee agrees to not copy and to return all such Agency supplied Information immediately upon termination of employment. Further employee agrees not to solicit any of the customers or employees of employer for any purpose for a period of two years after termination. This agreement shall be binding upon and inure to the benefit of the parties, their successors, assigns, and personal representatives.

RECEIPT OF EMPLOYEE HANDBOOK

This is to acknowledge that I have received a copy of the Agency Employee Handbook and understand that it sets forth the terms and conditions of my employment as well as the duties, responsibilities, and obligations of employment with the company. I understand and agree that it is my responsibility to read the Employee Handbook and abide by the rules, policies, and standards set forth in the Employee Handbook. I also acknowledge that my employment with our Agency is not for a specified period of time and can be terminated at any time for any reason, with or without cause or notice, by me or by the company. I acknowledge that no oral or written statements or representations regarding my employment can alter the foregoing. I also acknowledge that no Manager or Employee has the authority to enter into an employment agreement-express or implied-providing for employment other than at-will. I also acknowledge that, except for the policy of at-will employment, the company reserves the right to revise, delete, and add to the provisions of this Employee Handbook. All such revisions, deletions, or additions must be in writing and must be signed by the President of the company. No oral statements or representations can change the provisions of this Employee Handbook. I also acknowledge that, except for the policy of at-will employment, terms and conditions of employment with the company may be modified at the sole discretion of the company with or without cause or notice at any time. No implied contract concerning any employment-related decision, term of employment, or condition of employment can be established by any other statement, conduct, policy, or practice. I understand that the foregoing agreement concerning my at-will employment status and the company's right to determine and modify the terms and conditions of employment is the sole and entire agreement between me and our Agency concerning the duration of my employment, the circumstances under which my employment may be terminated, and the circumstances under which the terms and conditions of my employment may change. I further understand that this agreement supersedes all prior agreements, understandings, and representations concerning my employment with the company. If I have questions regarding the content or interpretation of this handbook, I will bring them to the attention of my supervisor.

FIELD EMPLOYEE STANDARDS AND PROCEDURES

This Agency requires adherence to the following Standards and Procedures: 1. All employees are expected to dress in a manner appropriate to the health care environment, or as directed by the patient/client/family. This includes personal hygiene, jewelry, hair and makeup. 2. Please do not smoke in the presence of a patient/client. 3. Always wear your ID Badge. 4. You are expected to arrive on time to all assignment that you have accepted. However, if an emergency or any situation should cause you to be five minutes late, or more or to be totally absent from the assignment you must notify the Agency immediately. PLEASE DO NOT CALL YOUR PATIENT DIRECTLY. You may call the Agency 24 hours a day if you need to cancel or reschedule your assignment. A NO-CALL, NO-SHOW IS GROUNDS FOR TERMINATION! 5. If you have any problem, incident or accident on the job, do not discuss it with the patient/client, but call the Agency immediately. 6. If the patient/client asks you to stay longer than your assignment or to leave earlier, you must call the Agency first, for approval. 7. Paraprofessional personnel (i.e. Aides) hereby acknowledge that they WILL NOT, UNDER ANY CONDITIONS, DISPENSE OR ADMINISTER ANY MEDICATION. 8. UNDER NO CIRCUMSTANCES are you to ask for, or accept any money from your patient/client or take home property that belongs to the patient/client. 9. There shall not be any involvement with the patient/client’s financial affairs (i.e. check writing). 10. You are expected to honor the confidentiality of any patient/ client information which is obtained in the regular course of your employment. 11. No personal telephone calls should be made or received by you while on assignment. 12. Please do not discuss your pay or any other personal affairs with the patient/client/family. 13. As an employee of this Agency, you are not authorized to accept any direct employment that may be offered to you by your patient/client/family. If you are requested to do so, please have the patient/client contact us. 14. It is imperative that all signed notes and documentation including Daily Log, be filled out properly and returned to the office as per our schedule. If the patient/client is unable to sign your note, a family member or responsible party may sign. 15. During the course of employment, this Agency’s proprietary materials (i.e. forms, medical records) will be used only in connection with employment and will not be disclosed to anyone without authorization from the Agency.

CONFIDENTIALITY AND NON-COMPETITION AGREEMENT

The Agency requires that the Employee avoid disclosure of confidential information to anyone outside of the Agency and refrain from engaging in unfair competition. The Employee agrees to refrain from prohibited competition with the Agency and to maintain the confidentiality of information regarding employees, clients and the Agency business. The Employee will have access to information not generally made available to the public, such as identity of clients, pricing, computer-related programs, etc. The Agency prohibits the utilization of this information for any purposes other than for the Agency's own benefit and prohibits disclosure or unauthorized use during the course of employment or at any time thereafter of any confidential information pertaining to Agency administration and/or projects, or outside investigations of the Agency. The employee is prohibited from disclosing any defaming information regarding Agency personnel and/or personnel incidents related to any violations of the personnel policies. During the course of employment and for a twelve month period thereafter the Employee is prohibited from engaging in any of the following: induce any employee of the Agency to resign, encourage any client or entity to discontinue any relationship with the Agency, solicit any client of the Agency (current and within the past twelve month period), enter into competitive employment or seek to provide competitive services while employed within twenty-five miles of any office of the Agency, or solicit referrals or opportunities from any referral source. Upon termination of employment or at the request of the Agency, the Employee is required to return all of the Agency's property including keys, client records, ID badge, forms, manual, beeper, etc. to the Agency and will not retain copies. Violation of this agreement will result in termination and any additional remedy available to the Agency including legal action to remedy all damages including loss of profits, cost of replacing and training employees improperly solicited for competitive employment, etc. suffered by the Agency. Employee will be required to reimburse the Agency for all legal fees, costs and other expenses. This agreement is in effect during the Employee's employment and for twelve months thereafter. It does not modify the right of the Employee to resign at any time or of the Agency to terminate employment without prior cause, notice or liability and does not modify any other Agency policy.

EMPLOYEE POLICIES AND PROCEDURES

I understand that copies of policy and procedure manuals are available and that it is my responsibility to read, understand and conform to all applicable Agency policies including personnel policies. It is also my responsibility to comply with periodic changes and revisions. I have read the Agency’s Policy and Procedure on Abuse, Neglect and Exploitation and agree to Comply with and am bound by the Policy. I understand that information contained in any Agency manual does not constitute a contractual relationship between the Agency and its employees, nor is it an expression of my term of employment. I affirm that I have auto insurance coverage as required by this state and the Agency and I agree to keep it fully in force on any vehicle I use for the conduction of Agency business during the term of my employment. The Agency has the right to request proof of insurance at any time during the term of employment and that I am required to follow all Agency requirements and state and local laws. I understand that only the Agency has the authority to admit clients and will supervise with appropriate personnel all services provided. As a caregiver, I will carry out the plan of treatment, submit timesheets, clinical and progress notes as appropriate and, at a minimum, on a weekly basis, I will participate in developing and reviewing plans of care, periodic client evaluations and care conferences, discharge planning and schedule coordination. I will provide services within the geographic area covered by the Agency. I will attend required staff meeting and in-service training. Home health aides are required to have 12 hours of in-service training annually. I understand that I must remit documentation of services performed prior to payment for those services and that payroll procedures require timely and accurate completion of documentation that must be submitted prior to payment for services provided. I understand that all information, both written and verbal, regarding client and employee health conditions is strictly confidential and protected under federal and state law. The presence of a communicable or venereal disease; testing, results or known infection by HIV, Hepatitis, Tuberculosis; information concerning child abuse, mental health, drug or alcohol abuse is protected under specific law. All information in connection with the examination, care or provision of services to any client will not be disclosed without the individual's written consent except as may be necessary to provide services as required by law. Information may be used in statistical or other summary form or for clinical purposes only if the identity of the individual is not disclosed. I understand the violation of client/ employee confidentiality is subject to civil and criminal penalties. If I mistakenly exceed my accrued or earned sick or vacation leave balance, I authorize the Agency to deduct any amount from my paycheck(s) to correct my accrued or earned sick or vacation leave balance. I understand that this company does not routinely perform drug testing on its employees but may do so at its discretion. I understand that this company is an “At Will” organization and may hire and fire at will.

CORPORATE COMPLIANCE POLICY

As you know, our Home Health Care Agency and our Staff members have always been committed to providing exceptional health care and upholding ethical conduct standards and legal compliance. Our policy formally and clearly states that there is a zero tolerance to any form of fraud or misconduct. This Agency believes that every employee or agent plays a key and active role in maintaining its image and reputation. I hereby acknowledge that I have apprised of and agree to comply with the Agency’s Corporate Compliance Policy. I understand that in no way does this create an obligation or contract of employment and that I, as well as the Agency, have the right to end the employment relationship at any time.

Home Health Aide Scope of Practice

HOME HEALTH AIDES SHOULD NEVER DO THESE 1. Administer over the counter medications that the patient will swallow. 2. Administer oral prescription medications. 3. Apply topical prescription medications ...(in mouth, eyes, ears, nose, on skin, or suppositories, etc) 4. Perform tasks that require the use of sterile technique (dressings, insertion of catheters, blood draws, etc) 5. Give fluids or food through feeding tubes. 6. Administer enemas. 7. Change colostomy pouches or other ostomy pouches.

DRESS CODE

Objective Infinity Health Care Services strives to maintain a workplace environment that is well functioning and free from unnecessary distractions and annoyances. As part of that effort, the company requires employees to maintain a neat and clean appearance that is appropriate for the workplace setting and for the work being performed. To that end, Infinity Health Care Services department heads may determine and enforce guidelines for workplace-appropriate attire and grooming for their areas; guidelines may limit natural or artificial scents that could be distracting or annoying to others. Procedures All Infinity Health Care Services staff members are expected to present a professional image to customers, visitors and the public. This means all field staff workers must be in scrubs. Supervisors should communicate any workplace specific attire and grooming guidelines to staff members during new-hire orientation and evaluation periods. Any questions about the department’s guidelines for attire should be discussed with the immediate supervisor. Any staff member who does not meet the attire or grooming standards set by his or her department will be subject to corrective action. Addressing workplace attire and hygiene problems Violations of the policy can range from inappropriate clothing items to offensive perfumes and body odor. If a staff member’s dress or poor hygiene is an issue, the supervisor should discuss the problem with the staff member in private and should point out the specific areas to be corrected. If the problem persists, supervisors should follow the normal corrective action process. APPROPRIATE Pants Dress Pants/Slacks Jeans (must be clean and free of rips(Friday only), tears and fraying; may not be excessively tight or revealing) Skirts and caprice SCRUBS (FIELD STAFF) Shirts Polo collar knit or golf shirts Oxford shirts Company logo wear Short-sleeve blouses or shirts Turtlenecks Blazers or sport coats Jackets or sweaters Company SCRUBS (FIELD STAFF) Shoes Boating or deck shoes, moccasins Casual, low-heel, open-back shoes (e.g., mules, sling backs) Sneakers (FIELD STAFF). INAPPROPRIATE Pants Sweatpants, leggings, exercise wear Shorts, low-rise or hip-hugger pants or jeans Shirts Shirts with writing (other than company logo) T-shirts or sweatshirts Beachwear Sleeveless blouses or shirts Exercise wear Crop tops, clothing showing midriffs, spaghetti straps Shoes thongs, flip flops, Athletic shoes, tennis shoes, Croc-like sandals ( athletics are ok for field staff)

ELECTRONIC DOCUMENTATION AND SIGNATURE AUTHENTICITY AGREEMENT

I understand that Agency staff may use electronic signatures on all computer-generated documentation. An electronic signature will serve as an authentication on patient record documents and other agency documents generated in the electronic system. For the purpose of the computerized medical record and other documentation for agency purposes, I acknowledge my use of the Signature Passcode and my Login authentication password will serve as my legal signature. I further understand that the Administrator issues employee passwords and the Signature Passcodes are issued by the software application. Signature Passcodes and passwords will be changed on an as needed basis if system security is breached. I understand that prior to exporting documentation to the agency server, I am required to review and authenticate, by use of an electronic signature, my documentation on the field-based or office computer. (OASIS Comprehensive Assessments will not require electronic signature until the required information is obtained, which may be up to five days after the corresponding MO date i.e.: MOO30, MOO32 etc.) I understand that: I cannot divulge my login password, Signature Passcode, I must exit the computerized application at the end of each working day or whenever the computer is not in my immediate possession, I must type in (rather than save) the login password that allows me access to the agency computer network, and my Signature Passcode. I must review all of my documentation online prior to submitting to the agency server.

HEALTH STATEMENT

I hereby attest that the state of my health is such that it will enable me to perform the duties of a health care professional. I further specifically attest that I am free of any and all potentially contagious diseases including, but not limited to: AIDS Anthrax Chickenpox Cholera Diphtheria Encephalitis Hepatitis, Types A, B and C Influenza Leprosy (Hansen’s Disease) Leptospirosis Malaria Measles (Rubeola) Meningitis Mononucleosis Mumps Whooping Cough Plague Poliomyelitis Psittacosis (Ornithosis) Rabies Rocky Mountain Spotted Fever Rubella (German Measles) Shigellosis Smallpox Tetanus Tularemia Tuberculosis Typhoid Fever

HEPATITIS VACCINE REQUIREMENT

ACCEPTANCE: I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of being infected by bloodborne pathogens, including Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV). This is to certify that I have been informed about the symptoms and the hazards associated with these viruses, as well as the modes of transmission of bloodborne pathogens. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. In addition, I have received information regarding the Hepatitis B (HBV) vaccine. Based on the training I have received, I am making an informed decision to accept the Hepatitis B (HBV) vaccine.

DECLINATION: I understand that due to my occupational exposure to blood or other potentially infectious materials I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me.

HEPATITIS VACCINE REQUIREMENT DECLINE OR ACCEPT*

TB TARGETED MEDICAL QUESTIONNAIRE FORM

This form is completed annually for those employees who have documentation of a negative chest x-ray following a positive Mantoux screening test, and whose medical evaluation and chest x-ray indicates that no further Mantoux screening is required.

Bad cough that lasts longer than 2 weeks*

Coughing up sputum (phlegm)*

Coughing up blood*

Unexplained weight loss*

Loss of Appetite*

Weakness, Fatigue, Tiredness*

Night Sweats*

Fever*

Chills*

Have you recently spent time with someone who has infectious tuberculosis*

If you have spent time with someone who has tuberculosis, Please explain:

Do you have any of the following risk factors which may substantially? Increase the risk of tuberculosis?*

N/A - Not Applicable

Silicosis (Lung Disease)

Gastrectomy

Intestinal Bypass

Weight 10% or more below ideal body weight?

Chronic Renal Disease

Diabetes Mellitus

Prolonged high-dose corticosteroid therapy or other

Immunosuppressive therapy

Hematologic Disorder i.e. leukemia or lymphoma

Exposure to HIV or AIDS

Other malignancies

TB Risk Assessment

Please fill out this Self Assessment to the best of your knowledge

Temporary of Permanent residence of >1 month in a country with a high TB rate*

Any country other than the United States, Canada, Australia, New Zealand, and those in Northern Europe or Western Europe

Current or Planned immunosuppression*

including human immunodeficiency virus (HIV) infection, organ transplant recipient, Treatment with a TNF-Alpha antagonist (e.g. infliximab, etanerce[t, or other) chronic steroids (the equivalent of prednisone >15 mg/day for >1 month) or other immunosuppressive medication

Close contact with someone who has had infectious TB disease since the last TB test*

Employee Self Assessment

Please fill out this Self Assessment to the best of your knowledge

Temperature*

Incontinence care*

Pulse and Respiration*

Bed bath*

Sponge, Tub*

Shower Bath*

Shampoo in bed*

Empty Foley Catheter*

Nail care*

Back Rub*

Oral Hygiene*

Assist with Meds*

Urinal*

Bed Pan*

Transfer Techniques*

Hoyer*

Ambulation*

Range of Motion*

Positioning*

Elevate Feet*

Make Occupied Bed*

Cane*

Dressing Assist*

Foot Soaks*

Walker*

Wheelchair*

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Employee Competence Assessment

Please fill out this Self Assessment to the best of your knowledge

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Temperature

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Incontinence care

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Pulse and Respiration

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Bed bath

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Sponge, Tub

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Shower Bath

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Shampoo in bed

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Empty Foley Catheter

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Nail care

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Back Rub

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Oral Hygiene

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Assist with Meds

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Urinal

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Bed Pan

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Transfer Techniques

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Hoyer

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Ambulation

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Range of Motion

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Positioning

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Elevate Feet

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Make Occupied Bed

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Cane

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Dressing Assist

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Foot Soaks

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Walker

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Wheelchair

Background Check Authorization

Notification The position for which I am being considered requires me to consent to a criminal background check as a condition of employment. This check includes the following: Criminal history reference searches for felony and misdemeanor convictions at the county and federal levels of every jurisdiction where I currently reside or where I have resided during the past 7 years; and sex offender registry searches at the county and federal levels in every jurisdiction where I currently reside or where I have resided.

Authorization I hereby authorize Infinity Healthcare Services to conduct the criminal background check described above. In connection with this, I also authorize the use of law enforcement agencies and/or private background check organizations to assist Infinity Healthcare Services in collecting this information. Validity Screening Solutions has been secured as a third party vendor (consumer reporting agency) to assist infinity Healthcare Services in collecting and verifying information. I also am aware that records of arrests on pending charges and/or convictions are not an absolute bar to employment. Such information will be used to determine whether the results of the background check reasonably bear on my trustworthiness or my ability to perform the duties of my position in a manner which is safe for infinity Healthcare Services clients and employees. I do understand that I am responsible for the full cost of this background check. To the best of my knowledge, the information provided in this Notice and Authorization and any attachments thereto is true and complete. I understand that any falsification or omission of information may disqualify me for this position and/or may serve as grounds for the severance of my employment with infinity Healthcare Services. By signing below I hereby provide my authorization to infinity Healthcare Services to conduct a criminal background check.

Banking Information

Do you have a Checking Account or Cash Card*

I have a Checking Account / Cash card

No, I Do Not Have a Checking Account or Cash Card

I need i Cash card

The information below is connected to*

Checking Account

Savings Account

I Do Not have any of these

Account Number

Confirm Account Number

Routing Number

Confirm Routing Number

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL I Authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that may result from furnishing the same to the Agency. I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time. I hereby request and authorize the agency to request and receive from all prior employers within one year of the date of application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination. I Agree to hold harmless these persons of organization, their offices, Directors Employees and Agents, owners, of Liability, Claims, damages or demands of any nature arising from or related to the investigation of the information contained in my applications.*

Signature Print your name

Date of Birth*