High School

College

Business or Trade School

Professional School

Please list your work experience for the past five years, beginning with your most recent job held. If you were self-employed, give the firm name. Attach additional sheets if necessary.

AN EQUAL OPPORTUNITY EMPLOYER
Supreme Touch Home Health Services Corp.

I HEREBY CERTIFY that my answers to the foregoing questions are true and complete and that I have not knowingly withheld any facts, circumstances or other information which would, if disclosed, affect my application. I further understand that any false or misleading statement or omission of pertinent information will result in the rejection of my application, or in dismissal if discovered subsequent to my employment.

I HEREBY AFFIRM that by execution of the application, I acknowledge that the Company has disclosed to me that an Investigative Consumer Report, including information as to my character, general reputation, personal characteristics, and mode of living may be made; and that I, upon written request to the Company made within a reasonable time after the date of this application, may obtain a complete and accurate disclosure of the nature and scope of the investigation requested.

I HEREBY AUTHORIZE the Company to request, and I ALSO AUTHORIZE AND REQUEST each former employer, school attended, and each person, firm, or corporation given as references above, to furnish at any time, any information which may be sought concerning me and my work habits, character or skill, and any other data required, whether in connection with this application or for purposes of complying with surety company requirements or otherwise.

I HEREBY AFFIRM that by submitting this application I agree to submit to medical evaluations end/or examinations, including tests for the presence of illegal drugs or alcohol, prior to and during employment, within a time period prescribed by the Company and as often as directed during employment.

I HEREBY AUTHORIZE the medical examiner to disclose to the Company any and all findings and conclusions arrived at in any examination performed either prior to employment or during employment.

I UNDERSTAND that should I be given employment, such employment shall be for an indefinite period of time and may be terminated, at will, at anytime, for any reason, by me or by the Company without notice or without liability whatsoever, except for unpaid wages or salary earned by the date of termination. I further understand that only the Director of Supreme Touch Home Health Services Corp. has the authority to enter into any agreement for employment for a specified period of time or to make any agreement contrary to this at will standard and that any such agreement must be in writing.

I UNDERSTAND that if I am employed, the terms and conditions of my employment will be governed by this application and the Company's Terms of Employment and Policy and Procedures, as amended from time to time by the Company.

The Company operates under the principles of affording equal employment opportunity through affirmative action for qualified handicapped individuals, qualified veterans of the Vietnam era and qualified disabled veterans.

All applicants and employees who believe themselves to be members of one or more of these groups, and who wish to identify themselves as such for the purpose of affirmative action consideration, are invited to do so.

Submission of this information is voluntary, and refusal to provide it will not subject you to discharge or disciplinary treatment. Information obtained concerning individuals shall be kept confidential, except that (1) supervisors and managers may be informed regarding disabled veterans and handicapped individuals, as necessary, (2) first aid and safety personnel may be informed, when and to the extent appropriate, if the condition might require emergency treatment, and (3) governmental officials investigating compliance will be informed.

I wish to volunteer the following Information (check one)

I do not qualify

I do qualify under the following:

Handicapped

Vietnam Era Veteran

Disabled Veteran