****2 References Required

I hereby release from all liability the company or person completing this form, and authorize them to release all information regarding my employment with them. I understand that this information may be released to clients of the requesting company andother requesting third parties on a need to know basis. I also release the requesting company from all liability for any damages fromthe disclosure of this information.

Please review and sign In making application for employment:

 I certify that the information in this application is true and complete for all practical purposes. It may be verifiedby the Agency or any affiliate. Should a position be offered and later it is found that the information issignificantly untrue, incomplete, or misrepresented, I understand and agree that the Agency or its affiliates arerelieved of all commitments, financial or otherwise pertinent to employment, and that I am subject toimmediate termination without recourse.

 I understand and agree that if I am offered employment by the Agency, my employment will be for no definiteterm and that either I, or the Agency will have the right to terminate the employment relationship at any time,with or without cause, and with or without notice. I also understand that this status can only be altered by awritten contract of employment which is specific as to all material terms and is signed by me and theAdministrator of the Agency.

 I understand, if I have direct patient contact that the Agency will perform a background check, including criminalhistory check, OIG exclusion list check (if applicable), and any additional checks as required by accrediting bodystandards or State Regulations. I further understand, if I am an unlicensed person, the Agency will perform acheck of the Nurse Aide Registry and Employee Misconduct Registry. I understand that:

1) the purpose of theEmployee Misconduct Registry is to ensure that unlicensed personnel who commit acts of abuse, neglect,exploitation, misappropriation, or misconduct against residents and consumers are denied employment in HHS-regulated facilities and agencies;

2) the State of Texas maintains a registry of all nurse aides who are certified toprovide services in nursing facilities and skilled nursing facilities licensed by the Texas Health and HumanServices (HHS) and they review and investigate allegations of abuse, neglect, or misappropriation of residentproperty by nurse aides and if there's a finding of an alleged act of abuse, neglect, or misappropriation, the nurse aide may request both an informal reconsideration and a formal hearing before the finding is placed onthe registry;

3) All HHS-regulated facilities and agencies are required to check the Employee Misconduct Registryand Nurse Aide Registry before hire to determine if I am listed in either registry as having committed an act of abuse, neglect, exploitation, misappropriation, or misconduct against a resident or consumer and am, therefore,unemployable. I understand that a refusal to authorize the criminal background check may result in adverse employment action, such as rejection of the application or termination of employment.

Release: I hereby authorize any prior employers to provide such information concerning my employment withthem as may be requested, and also authorize the Registrar / Placement Office of all educationalinstitutions attended to release an official copy of my transcript and, if available, faculty appraisals. I also authorize any appropriate licensing board to release full information concerning my license statusand my license history.

Pursuant to Title VII of the Civil Rights Act of 1965 (42 U.S.C., §20000d et seq.) and 4.5 C.F.F. Part 80, §504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §6101 et seq.), Americare In Home Care adheres to an equal opportunity policy for all persons seeking admission as clients or seeking employment and for all persons employed by Americare In Home Care. Americare In Home Care offers equal employment and advancement opportunities to qualified individuals without regard to race, color, religion, sex, age, national origin, marital status, disability or any other category protected by any applicable local, state, federal law, ordinance or regulation.

I HEREBY AGREE THAT I WILL NOT SOLICIT, EITHER DIRECTLY OR INDIRECTLY, ON BEHALF OF MYSELF OR ANY OTHER PERSON, FIRM OR CORPORATION, EMPLOYMENT FIRM OR CORPORATION, EMPLOYMENT FROM A CLIENT OF THIS COMPANY WHICH I HAVE BEEN SENT OR REFERRED TO FOR EMPLOYMENT OR PROSPECTIVE EMPLOYMENT FOR A PERIOD OF 90 DAYS FROM THE LAST TIME I WAS EMPLOYED OR
REFERRED TO FOR EMPLOYMENT TO SAID CLIENT, THE IDENTITY OF ANY CLIENT OR PROSPECTIVE CLIENT OF OR ACQUIRED THROUGH THE COMPANY SHALL BE DEEMED CONFIDENTIAL INFORMATION. IT IS SPECIFICALLY UNDERSTOOD THAT ANY VIOLATION OF THE ABOVE SHALL SUBJECT ME TO THE SUM
OF $750.00 AS DAMAGES. I AGREE TO A SEARCH OF THE NURSE AIDE REGISTRY AND THE EMPLOYEE MISCONDUCT REGISTRY AND I UNDERSTAND THAT IF I AM LISTED ON THESE REGISTRIES, I MAY NOT BE
EMPLOYED BY AMERICARE. I FURTHER AGREE TO A CRIMINAL HISTORY CHECK AND HAVE NO CONVICTION FOR AN OFFENSE DESCRIBED IN THE HEALTH AND SAFETY CODE 250-005.
Equal Opportunity Employer

STATEMENT OF EMPLOYABILITY
By execution of this document, I acknowledge that I have been informed by the Agency and agree that the Agency mayconduct a State of Texas criminal history check per Texas H&SC 250.006. I agree to a search of the Nurse Aide Registryand the Employee Misconduct Registry prior to employment and at least every 12 months if hired. As required, I agreeto a search of the Texas Health and Human Services Commission’s OIG List of Excluded Individual/Entities, prior to beinghired and monthly thereafter, the HHS - OIG Excluded Individuals/Entities Search Database and SAM Exclusion List. Iunderstand that these checks will determine if I have a criminal conviction or have committed certain conduct that willbar me from employment with this Agency. I understand that I am unemployable if listed as unemployable in the NAR orEMR per TAC 26 TAC Chapter 561, §561.3 and Texas H&SC Chapter 253
CONVICTIONS BARRING EMPLOYMENT.
(A) A person for whom the facility is entitled to obtain criminal history record information may not be employed in a facility if the person has been convicted of an offense listed in this subsection:
♦ An offense under Chapter 19, Penal Code (criminal homicide);
♦ An offense under Chapter 20, Penal Code (kidnaping and unlawful restraint);
♦ An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or children);
♦ An offense under Section 21.08, Penal Code (indecent exposure);
♦ An offense under Section 21.11, Penal Code (indecency with a child);
♦ An offense under Section 21.12, Penal Code (improper relationship between educator and student);
♦ An offense under Section 21.15, Penal Code (improper photography or visual recording);
♦ An offense under Section 22.011, Penal Code (sexual assault);
♦ An offense under Section 22.02, Penal Code (aggravated assault);
♦ An offense under Section 22.021, Penal Code (aggravated sexual assault);
♦ An offense under Section 22.04, Penal Code (injury to a child, elderly individual, or a disabled individual);
♦ An offense under Section 22.041, Penal Code (abandoning or endangering a child);
♦ An offense under Section 22.05, Penal Code (deadly conduct);
♦ An offense under Section 22.07, Penal Code (terroristic threat);
♦ An offense under Section 22.08, Penal Code (aiding suicide);
♦ An offense under Section 25.031, Penal Code (agreement to abduct from custody);
♦ An offense under Section 25.08, Penal Code (sale or purchase of a child);
♦ An offense under Section 28.02, Penal Code (arson);
♦ An offense under Section 29.02, Penal Code (robbery);
♦ An offense under Section 29.03, Penal Code (aggravated robbery);
♦ An offense under Section 32.53 Penal Code (exploitation of a child, elderly individual, or disabled individual);
♦ An offense under Section 33.021, Penal Code (online solicitation of a minor);
♦ An offense under Section 34.02, Penal Code (money laundering);
♦ An offense under Section 35A.02, Penal Code (Medicaid fraud);
♦ An offense under Section 36.06, Penal Code (obstruction or retaliation);
♦ An offense under Section 42.09, Penal Code (cruelty to livestock animals);
♦ An offense under Section 42.092, Penal Code (cruelty to non-livestock animals); or
♦ A conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense listed by this subsection.
(B) An offense the Agency determines to be contraindicated to employment with the consumers the A person may also be barred from employment the duties of which involve direct contact with a client in a facility if convicted of any of the
following crimes within the past 5 years:
♦ An offense under Section 22.01, Penal Code (assault punishable as a Class A misdemeanor or as a felony);
♦ An offense under Section 30.02, Penal Code (burglary);
♦ An offense under Chapter 31, Penal Code (theft that is punishable as a felony);
♦ An offense under Section 32.45, Penal Code (misapplication of fiduciary property or property of a financial institution), that is punishable as a Class A misdemeanor or a felony; or
♦ An offense under Section 32.46, Penal Code (securing execution of a document by deception punishable as a Class A misdemeanor or a felony) .
♦ An offense under Section 37.12, Penal Code (false identification as a peace officer); or
♦ An offense under Section 42.01 (a) (7), (8), or (9), Penal Code (disorderly conduct).
(C) In addition to the prohibitions on employment prescribed by Subsections (A) and (B), a person for whom a facility licensed under Chapter 242 or 247 is entitled to obtain criminal history record information may not be employed in a facility licensed under Chapter 242 or 247 if the person has been convicted:
♦ Of an offense under Section 30.02, Penal Code (burglary); or
♦ Under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing elements that are substantially similar to the elements of an offense under Section 30.02, Penal Code.
(D) For purposes of this section, a person who is placed on deferred adjudication community supervision for an offense listed in this section, successfully completes the period of deferred adjudication community supervision, and receives a dismissal and discharge in accordance with Section 5(c), Article 42.12, Code of Criminal procedure, is not considered convicted of the offense for which the person received deferred adjudication community supervision.

I acknowledge that if I am found to have been convicted of any other offense(s), that these offenses may also bar my employment. I understand that all information obtained by this agency regarding any criminal history will remain confidential.

I certify that the information on this form contains no willful misrepresentation and that the information given is true and complete to the best of my knowledge.