I understand that my application process is subject to approval for employment and will be under consideration due to my qualifications, criminal history check nationally and in all state counties ever resided, sex offender searches, and any risk for the reasons Assured Home Healthcare, Inc. follows under federal, state, and local laws and codes in accordance to their company and employment policies.

As of June 30, 2010; Indiana Code 16-27-2-4 Section 5 states in the following: home health agencies in Indiana as Assured Home Healthcare, Inc. may not employ a person to provide services in a patient’s temporary or permanent residence if that person’s limited criminal history, national criminal history background check, or expanded criminal history check indicates that the person has been convicted of (1) rape (IC 35-42-4-1), (2) criminal deviate conduct (IC 35-42-4-2), (3) exploitation of an endangered adult (IC 35-46-1-12), (4) failure to report battery, neglect, or exploitation of an endangered adult (IC 35-46-1- 12), (5) theft (IC 35-43-4) if the conviction for theft occurred less than ten (10) years before the person’s application date, a felony that is substantially equivalent to a felon listed in (A) subdivisions (1) through (4); or subdivision (5), if the conviction for theft occurred less than ten (10) years before the person’s employment application date; for which the conviction was entered in another state.

I understand that an offer of employment would be subject to my satisfactorily passing a physical examination. I consent to and will obtain a physical examination by a physician or nurse practitioner at that time and at any future time. I understand that I may be required to satisfactorily complete an alcohol/drug screening as a condition of employment. I understand that the Agency is a health care provider and may have a no-smoking policy and I agree to comply with its requirements. I understand that my employment can be terminated at any time and for any reason, at the option of either the facility or myself. I understand that no one has the authority to enter into any agreement for employment for any specified period or to make any agreement contrary to the foregoing, except for a written employment agreement signed by and administrative representative of this Agency.

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions may disqualify me form further consideration for employment and may result in discharge even if discovered later.

I hereby authorize and request without reservation any persons, schools, my current and previous employer(s), and organizations named in this application (and accompanying resume, if any), as well as police department, financial institution, division of motor vehicles, consumer reporting agencies, or other persons or agencies having knowledge about me, to provide Assured Home Healthcare, Inc. and all its affiliates with any relevant background information in their possession regarding me, in order my employment qualifications may be evaluated, and release all such persons from any liability regarding the provision or use of such information.