14. Provisional Hiring Affirmation

Name*

First NameLast Name

Provisional Hiring Affirmation/Disclosure

In accordance with 611.54 of the Home Care Agency licensing regulations, you may be hired on a provisional basis pending receipt of a criminal history report if the following conditions are met.

Applicant Name: (Please Initial)

false alteration of, any record or document.

complete disclosure. I understand that while I am in provisional status

I have NOT tampered with public record information by making a false entry in, orIhave NOT committed a crime that could disqualify me from employment withoutIwill be monitored by Galaxy Home Care through random, direct observation andI understand if I have been a Pennsylvania resident for 2 years or more, I cannot

consumer feedback, and results will be documented in my file.

serve a provisional period of more than 30 days; and if I have NOT been a resident of Pennsylvania for 2 years or more, I cannot serve a provisional period of more than 90 days. Any prior convictions to the best of your ability/knowledge:

I attest that the above information is true to the best of my knowledge and swear and affirm that I have not been named or convicted of any crime that has not been disclosed and if I am so named or convicted at any time during my employment, I will advise my employer, Galaxy Home Care, of that fact. I understand that my employment may be terminated if I have been named or convicted of any crimes so as described prior to employment or at any time during my employment.

Applicant Signature*

Date

Galaxy Home Care RepresentativeTitle Fax: +1 (215) 565-0733 Phone: +1 (215) 588-5068 101 Coventry CirLansdalePA 19446-6400 Email: info@galaxyhomecarellc.com