The Ohio Administrative Code (5123:2-05) requires that home health care companies ascertain from applicants for employment that have been convicted or plead guilty of the offenses listed below: Your signature below indicates that you have not committed nor plead guilty to: Aggravated murder, murder, voluntary manslaughter, involuntary manslaughter, felonious assault, aggravated assault, assault, failing to provide for a functionally impaired person, aggravated menacing, patient abuse and neglect, kidnapping, abduction, gross sexual imposition, importuning, voyeurism, public indecency, compelling prostitution, promotion prostitution, procuring prostitution, disseminating matter harmful to juveniles, pandering obscenity involving a minor, illegal use of a minor, in nudity oriented material or performance, aggravated robbery, robbery, aggravated burglary, burglary, unlawful abortion, endangering children, contributing to the unruliness or delinquency of a child, domestic violence, carrying a concealed weapon, having weapons while under disability, improperly discharging a firearm at or into a habitation or school, corrupting others with drugs, trafficking in drugs, illegal manufacturing of drugs or cultivation of anabolic steroids, placing harmful objects in food or confection, child stealing, possession of drugs, felonious sexual penetration.

I have read the contents of this addendum to my application for employment with Devine Healthcare Services LLC. I also understand that I am required by law to notify Devine Healthcare Services LLC within 14 (fourteen days if I receive formal charges, convictions, or make a guilty plea to any one of the disqualifying offenses listed above.

Respond to ALL questions. If a particular question does not N/A in the appropriate space. Please PRINT CLEARLY. Incomplete applications will not be considered.

Equal Opportunity Employer: DHS will not discriminate against any employee or applicant for employment because of race, color, religion, sex, age, national origin, ancestry, citizenship status, disability, handicap or any other legally protected category. Any information received about this applicant will not be used for impermissible purposes.

I give Devine Healthcare Services MY PERMISSION TO OBTAIN A WORK RELATED REFERENCE FROM THE ABOVE MENTIONED FORMER EMPLOYERS AND TO USE MY SOCIAL SECURITY NUMBER IF NEEDED

The information I have provided in this Application for Employment is true, correct, and complete to the best of my knowledge. False, incomplete, or misrepresented information of any kind will be sufficient cause for my application to be rejected or, if discovered after I am employed, cause for immediate termination.

I, authorize Devine Healthcare Services LLC to contact and obtain information about from previous employers, educational institutes, and "references" I provided, and any other party necessary to verify the accuracy of information contained in this application, all interviews, or resumes. I waive all rights and claims I may otherwise have with DHS or its representatives, for seeking and using information to evaluate my employment report and all other persons, corporations or organizations who provide information for this purpose.

This application will expire in sixty (60) days. After that date, unless otherwise notified, I understand that my status as an applicant will end I will then need to re-apply for future employment consideration.

This application is not an employment agreement. If I am offered a position, and accept, I understand DHS may terminate any employment at any time without cause and without prior notice, unless required by law. I understand that no one, agreement with term contrary to the forgoing and then only administrative personnel will have access to your application.

I FULLY UNDERSTAND AND ACCEPT ALL TERMS AND CONDITIONS IN THE ABOVE STATEMENT.

Devine Healthcare Services LLC, is required by law to ask the following questions and may be required by law to report answers to government agencies responsible for supervising health care, nursing home, home care / or hospice activity.

I hereby certify that I have not been convicted and/or found guilty of resident or patient abuse, neglect or mistreatment, or of misappropriation of a resident property in the state, and that I am not listed in any resident or patient abuse registry in the state or in any other state. I understand that any offer of employment that is extended to me DHS is conditional upon the verification of this information with the state patient and that a sting in such registry or the registry of any other state may cat ad an automatic withdrawal of any such offer or employment by DHS LLC, location is conditional upon verification of my license or certification with appropriate state agency. In the event that I have not yet been licensed or certified and the event that I am offered employment with DHS LLC. I agree to undertake the required training and competency certification requirements immediately upon commencing employment

I understand that Devine Healthcare Services, LLC requires a thorough pre-employment background investigation. This investigation is limited to only that information required to determine fitness for employment and may include, but not limited to: employment history verification, job performance, disciplinary record, financial/credit history and a criminal background investigation, by singing this document, I AGREE TO HOLD HARMLESS any previous employer, agent, or corporation, or any individual or organization providing information pursuant to this authorization.

Please read carefully. If you have any questions feel free to ask. I certify that all of the statements made by me on this application for employment are true, current, and complete to the best of my knowledge.

As part of my employment with DHS, I give permission to have my finger prints submitted to BCII. Only employees needed in making employment decision or a Government audit shall have access to the results. I realize I am conditionally hired and if finger print check has violations as listed for a home health agency, I may be terminated.

I give DHS permission to contact all employers listed on the application (unless otherwise excluded) for references. I further give permission to all former employers and/or managers or supervisors to discuss any former work performance

I give my permission to receive a copy of any file of federal, state/local court. Governmental agency or law enforcement agency concerning information regards to my employment qualifications.

I understand or willful omission of fact made in this application or in connection with any background investigation may be sufficient grounds for rejection of this application, or, of discovered after employment, it will be grounds for immediate dismissal.

In consideration of my employment, I agree to confirm to the rules and regulations of HA, LLC., my employment and compensation is at "at will" in that I can be terminated with or without cause, and with amor without notice, at any time except as otherwise provided by law.

I agree to fully cooperate with DHS, LLC., background investigation and to sign any waiver or release that may be necessary to obtain access to relevant information, in the event that any former employer or federal, state, or local governmental agency will not release reference information or criminal history information directly to the employer. I agree to personally request such information to the extent permitted by law.