INSTRUCTIONS: Complete all questions (pages 1-4) Print all information requested except signature. Fax completed application to 321-499-4642. Note: Applicants may be tested for illegal drugs.

List two personal references. DO NOT LIST relatives or previous supervisors.

Please list at least two of your work experiences in the past five years beginning with your most recent job held. If you were self employed, give company name. Attach additional sheets if necessary.

How would you rate yourself on your experience with the following aspects of caregiving? 1 = No Experience 2 = Some Experience 3 = Good Experience 4 = Excellent Experience

In exchange for the consideration of my job application by Just A Friend Elder Care , I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Just A Friend Elder Care company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Just A Friend Elder Care, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President of the Just A Friend Elder Care. Both the undersigned and Just A Friend Elder Care may end the employment relationship at any time, without specified notice or reason. If employed, I understand that Just A Friend Elder Care may unilaterally change or revise their benefits, policies and procedures and such changes may include reduction in benefits.I also understand that (1) Just A Friend Elder Care has a drug and alcohol policy that provides for pre-employment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job related physical examinations.I understand that, in connection with the routine processing of your employment application, Just A Friend Elder Care may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, Just A Friend Elder Care will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.I hereby release any and all prior employers or current employers from liability or claims arising out of the provision of information about my employment with such employer. I hereby waive any cause of action I might otherwise have against such employer arising out of the provision of information concerning my employment.I further understand that my employment with Just A Friend Elder Care shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relation with Just A Friend Elder Care is terminable at will for any reason by either party.I CERTIFY THAT ALL ANSWERS GIVEN BY ME ARE TRUE, ACCURATE AND COMPLETE. I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give Just A Friend Elder Care permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release Just A Friend Elder Care from any liability as a result of such contract.

Just A Friend Elder Care is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this depends solely on your qualifications. Thank you for completing this application form and for your interest in our business. Please return this application to our office at your earliest convenience.