INSTRUCTIONS: 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. 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.

*In order to be able to run errands in an automobile, you will be required to have a valid driver's license and current auto insurance. A motor vehicle record check will be conducted and proof of insurance will be required.

For employment our minimum education requirement is either a GED or High School Diploma

Your application will not be considered unless all questions in this section are answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are essential.

**** Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check.

Please Complete 3 References. Your Application will not be considered unless all 3 references are provided. Since we will contact these references, please notify them in advance. If we are unable to reach all 3 references, you will be asked to provide additional References.

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 depends 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 you are 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.

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. I 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. | 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.