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Page84 111EMPLOYMENT APPLICATIONINSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.Please read "Applicant Note below.Complete all pages of this application.Print clearly. Incomplete or illegible applications may not be accepted.If more space is needed to complete any question, use comments section on the back.Application will be valid for 60 days.APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with our Home Care Agency. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body may be required prior to employment. EMPLOYMENT / JOB APPLICATIONPERSONAL INFORMATIONFULL NAME: DATE: First Middle LastADDRESS: Street Address Apt/SuiteCity State Zip CodeE-MAIL: PHONE: SOCIAL SECURITY NUMBER (SSN): - -DATE AVAILABLE: DESIRED PAY: $ HOUR SALARY POSITION APPLIED FOR: EMPLOYMENT DESIRED: FULL-TIME PART-TIME SEASONAL EMPLOYMENT ELIGIBILITYARE YOU LEGALLY ELIGIBLE TO WORK IN THE U.S.? YES NO* HAVE YOU EVER WORKED FOR THIS EMPLOYER? YES* NO*IF YES, WRITE THE START AND END DATES: HAVE YOU EVER BEEN CONVICTED OF A FELONY? YES* NO*IF YES, PLEASE EXPLAIN: Page85 111EDUCATIONHIGH SCHOOL: CITY / STATE: FROM: TO: GRADUATE? YES NO DIPLOMA: COLLEGE: CITY / STATE: FROM: TO: GRADUATE? YES NO DEGREE: OTHER: CITY / STATE: FROM: TO: DEGREE/CERTIFICATION: OTHER: CITY / STATE: FROM: TO: DEGREE/CERTIFICATION: PREVIOUS EMPLOYMENTEMPLOYER 1: Company / IndividualE-MAIL: PHONE: ADDRESS: Street Address Apt/SuiteCity State Zip CodeSTARTING PAY: $ HOUR SALARY ENDING PAY: $ HOUR SALARY JOB TITLE: RESPONSIBILITIES: FROM: TO: REASON FOR LEAVING: EMPLOYER 2: Company / IndividualE-MAIL: PHONE: ADDRESS: Street Address Apt/SuiteCity State Zip CodePage86 111STARTING PAY: $ HOUR SALARY ENDING PAY: $ HOUR SALARY JOB TITLE: RESPONSIBILITIES: FROM: TO: REASON FOR LEAVING: EMPLOYER 3: Company / IndividualE-MAIL: PHONE: ADDRESS: Street Address Apt/SuiteCity State Zip CodeSTARTING PAY: $ HOUR SALARY ENDING PAY: $ HOUR SALARY JOB TITLE: RESPONSIBILITIES: FROM: TO: REASON FOR LEAVING: REFERENCES(PROFESSIONAL ONLY)FULL NAME: RELATIONSHIP: First LastCOMPANY: TITLE: E-MAIL: PHONE: FULL NAME: RELATIONSHIP: First LastCOMPANY: TITLE: E-MAIL: PHONE: FULL NAME: RELATIONSHIP: First LastCOMPANY: TITLE: E-MAIL: PHONE: Page87 111BACKGROUND CHECK CONSENTIF ASKED, ARE YOU WILLING TO CONSENT TO A BACKGROUND CHECK? YES NO DISCLAIMERApplicant understands that this is an Equal Opportunity Employer and committed to excellence through diversity. In order to ensure this application is acceptable, please print or type with the application being fully completed in order for it to be considered.Please complete each section EVEN IF you decide to attach a resume. I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information in my application or interview may result in my employment being terminated. SIGNATURE DATE PRINT NAME Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years? Yes or No.APPLICANT NOTICE:It is illegal in Philadelphia for employers to ask about your criminal background during the job application process.Employers cannot ask about your criminal background on job applications or during any job interview. Employers can run your criminal background check ONLY AFTER a conditional offer of employment is made (final hiring depend on the results of your background check). Criminal convictions can be considered ONLY if they occurred less than 7 years from when you apply (not counting time of incarceration). Arrests that did not lead to conviction cannot be used in any employment decisions. If your background check reveals a conviction, the employer must consider: The type of offense and the time that has passed since it occurred. Its connection to the job youre applying for; and Your job history, character references, and any evidence of rehabilitation. Employers can reject you based on your criminal record ONLY if you pose an unacceptable risk to the business or to other people. If you are rejected, the employer must send the decision to you in writing with a copy of the background report used to make the decision. You have 10 days to give an explanation of your record, proof that it is wrong, or proof of rehabilitation.APPLICANT CERTIFICATION AND RELEASE:I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief.Page88 111I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize the company and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release this company from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between the Company and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I also understand that due to the nature of the business, no amount of work can be guaranteed.APPLICANT SIGNATURE DATE