If yes, please list conviction(s), date(s) and location(s). Te presence of a criminal record is not an automatic rejection of your application. Certain types of convictions will eliminate you from servicing vulnerable elders in their homes. I attest that the above referenced information is true and accurate to the best of my knowledge. I further give the agency permission to call and of my cited previous employers or reference candidate for information regarding my character, employment history or work ethic.

CERTIFICATION AND RELEASE: I certify that I have read and understand the application note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions, or misrepresentation of facts called for in this application may result in rejection of my application or discharge at any time during my employment. I authorize A&G Trusted Home Care and or its agents, including consumer reporting bureaus, to verify any information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies, and law enforcement authorities to release any information concerning my back round and hear by release any said persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I also understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.