Persons who can furnish information about job performance

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 herby 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 my result from furnishing the same to the Agency.

This Agency performs random drug screening and prohibits the use of illegal drugs. I understand that I will be subject to random drug screening and failure to submit or pass drug screening may result in dismissal for cause. By signing this application, I agree to submit to random drug screening as requested.

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.

To Whom It May Concern:

The applicant named below has submitted an application for employment with our firm. Please verify employment and rate the performance of this candidate. This information will not be given to the employee.

To be filled out by applicant:

Date of employment:

*In case of emergency, please contact:

*Please notify this Agency immediately if any of the emergency contact information changes.

Explanation and Instruction:

Our company policy requires all employees who have direct contact with patients in the home setting to submit a statement from an appropriately licensed health care professional, based on an exam performed within the last twelve months. The employee must show no apparen signs or symptoms of communicable disease.

Statement to be signed by a Physician or appropriately licensed Healthcare professional.

He/She is in adequate health to perform home health duties and show no apparent signs or symptoms of communicable disease.

If the answer is YES, please answer the following:

Answer “Yes” or “No”. Employee should be considered at risk for TB if any of the following statements are marked “Yes”.

acknowledge that I am at risk of exposure or have been unknowingly exposed to Hepatitis B as a result of my employment and acknowledge that the Agency will arrange for me to receive the Hepatitis vaccine at no cost to myself.