Freedom Home Health Care

I certify that any and all statements that I have set forth in this application are true and correct to the best of my knowledge. I understand that any omission or misrepresentation by me in this application are cause for possible cancellation of this application or, if employed, may be cause for dismissal, regardless of time of discovery. Any offer of employment is contingent upon completion of a successful background investigation. I further understand that if I am hired by Freedom Home Healthcare, Inc., I must agree, in writing, to comply with the Freedom Home Healthcare Employment Manual. Any employment resulting from this application will be employment at will. This means that an employee has the right to terminate their employment at any time for any reason, and the company may exercise the same right. All applicants for employment will be considered without regard to race, religion, color, national origin, sex, marital status, pregnancy status, age, disability, veteran status, sexual orientation, or sexual affectation. I _____________________________________ (Applicant) hereby authorize Freedom Home Healthcare, Inc. to request and receive from all prior employers, within 3 years of the date of this application, any and all pertinent information concerning my prior employment and its termination, including the reasons for such termination. I hereby release said companies, organizations, agents, individuals, and Freedom Home Healthcare, Inc. from any liability for any damage whatsoever resulting from the giving of such information.

I _____________________________________ (Applicant) hereby authorize Freedom Home Healthcare, Inc. to request and receive from all employers, within 3 years of the date of this application, any and all pertinent information concerning my employment and its termination, including the reasons for such termination. I also give Freedom Home Healthcare permission to obtain medical information of mine as required by the hiring standards. I hereby release said companies, organizations, agents, individuals, and Freedom Home Healthcare, Inc. from any liability for any damage whatsoever resulting from the giving of such information.