I have applied for employment, do hereby certify that I have never been shown by credible evidence by a court, a department investigation, or other reliable evidence to have abused, neglected, sexually assaulted, exploited, deprived any person or to have subjected any to serious injury as a result of intentional or grossly negligent misconduct as evidenced by an oral or written statement to this effect obtained at the time of application and have not made nay materials false statements concerning qualification requirement, either to the department or Gees Hope Caring Agency. In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in discharge.