In conjunction with the application and the contract for services, I understand that investigative background inquiries are to be made on myself including consumer, criminal, driving and other reports. These reports will include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employers. Further, I understand that you will be requesting information from various federal, state and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil, and other experiences as well as claims involving me in the files of insurance companies. I authorize, without reservation, any party or agency contacted by this employer to furnish the above mentioned information. I agree to pay $25.00 as the cost of background check.

I certify that I have read and understand the application on page one (1) of this form and that the answers given by me to the forgoing questions and the statements written by me are complete and true to the best of my knowledge and belief. I understand that any false information, omission or misrepresentation of facts presented in the 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 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 liability for any damage whatsoever for issuing this information. I understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior and during employment.

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I HEREBY CERTIFY that my answers to the foregoing questions are true and complete and that I have not knowingly withheld any facts, circumstances or other information which would, if disclosed, affect my application. I further understand that any false or misleading statement or omission of pertinent information will result in the rejection of my application, or in dismissal if discovered subsequent to my employment.

I HEREBY AFFIRM that by execution of the application, I acknowledge that the Company has disclosed to me that an Investigative Consumer Report, including information as to my character, general reputation, personal characteristics, and mode of living may be made; and that I, upon written request to the Company made within a reasonable time after the date of this application, may obtain a complete and accurate disclosure of the nature and scope of the investigation requested.

I HEREBY AUTHORIZE the Company to request, and I ALSO AUTHORIZE AND REQUEST each former employer, school attended, end each person, firm, or corporation given as references above, to furnish at any time, any information which may be sought concerning me and my work habits, character or skill, and any other data required, whether in connection with this application or for purposes of complying with surety company requirements or otherwise.

I HEREBY AFFIRM that by submitting this application I agree to submit to medical evaluations end/or examinations, including tests for the presence of illegal drugs or alcohol, prior to and during employment, within a time period prescribed by the Company and as often as directed during employment.

I HEREBY AUTHORIZE the medical examiner to disclose to the Company any and all findings and conclusions arrived at in any examination performed either prior to employment or during employment.

I UNDERSTAND that should I be given employment, such employment shall be for an indefinite period of time and may be terminated, at will, at anytime, for any reason, by me or by the Company without notice or without liability whatsoever, except for unpaid wages or salary earned by the date of termination. I further understand that only the Director of Unique Home Care Services has the authority to enter into any agreement for employment for a specified period of time or to make any agreement contrary to this at will standard and that any such agreement must be in writing.

I UNDERSTAND that if I am employed, the terms and conditions of my employment will be governed by this application and the Company's Terms of Employment and Policy and Procedures, as amended from time to time by the Company.

The Company operates under the principles of affording equal employment opportunity through affirmative action for qualified handicapped individuals, qualified veterans of the Vietnam era and qualified disabled veterans.

All applicants and employees who believe themselves to be members of one or more of these groups, and who wish to identify themselves as such for the purpose of affirmative action consideration are Invited to do so.

Submission of this information is voluntary and refusal to provide it will not subject you to discharge or disciplinary treatment. Information obtained concerning individuals shall be kept confidential, except that (1) supervisors and managers may be informed regarding disabled veterans and handicapped individuals, as necessary, (2) first aid and safety personnel may be informed, when and to the extent appropriate, if the condition might require emergency treatment, and (3) governmental officials investigating compliance will be informed.