I, the below-named applicant, understand that this form may not be fully processed until a conditional offer of employment or engagement has been made. Any offer of employment is contingent upon the results of required background studies, including but not limited to applicable state and federal registries and criminal background checks. I understand that refusal to complete this form, or any required portion of the background study process, may result in withdrawal of the conditional offer of employment. I affirm that the information provided on this form is true, complete, and correct to the best of my knowledge.

NOTE: If you answered YES to any of the questions above, you may be required to submit a written explanation. Failure to provide requested information may result in disqualification.

I hereby authorize Abriva Home Health Care LLC, and/or any appropriate state, federal, or authorized third-party agency, to conduct background studies and investigations for employment or service eligibility purposes. This may include, but is not limited to

Minnesota DHS Background Studies, Criminal history checks, Adult and child abuse registries

Fingerprint-based background checks (if required)

I understand that information obtained may be retained by the appropriate authorities and by Abriva Home Health Care LLC as permitted by law.

I further understand that falsification or omission of information on this application may result in denial of employment or termination.

I acknowledge that I have received and understand the Notice to Applicants regarding background studies.