I certify that I have read and understand the applicant note on page one of the employment application 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 misrepresentations of facts called for in this application may result in rejection of my application or discharge at any time during my employment.
I understand that this application is not a contract of employment and that if hired, regardless of any oral representations to the contrary, the employment relationship between CH Services, Inc. dba Home Instead Senior Care (“Home Instead”) and myself is terminable at will.
I understand that the use of illegal drugs is prohibited during employment. If Home Instead policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.
HOME INSTEAD SENIOR CARE BACKGROUND AND REFERENCE CHECK AUTHORIZATION, CONSENT AND WAIVER
I authorize CH Services, Inc. d/b/a Home Instead Senior Care ("Home Instead") and/or its agents to make whatever inquiries it may deem necessary in connection with my course of employment. As part of such inquiries, Home Instead has my permission to conduct an investigation of my background, references, character, employment, motor vehicle, education, and criminal history record information.
A history of a conviction of crime will not necessarily disqualify an applicant from employment. As related to the position applied for, a review of the age and time of the offense, seriousness and nature of the violation, rehabilitation or current state law requirements will be taken into account.
I authorize Home Instead to obtain a consumer report, which may consist of criminal background information and investigative reports bearing on job performance. I agree and understand Home Instead may obtain information which may be in any state or local files, including those maintained by both public and private organizations, and all public records, for the purpose of confirming the information contained in my application and/or obtaining other information which may be material to my qualifications for employment. I also authorize Home Instead to obtain any and all information from former employers including, but not limited to, performance, achievement, attendance, disciplinary information, reason for termination, and work history. I further authorize Home Instead to provide a copy of this document to any such former Employer (or current or former employee or agent thereof) and direct such party to release such information to an authorized employee of Home Instead regardless of any agreement between us to the contrary or any other policy to the contrary. I further authorize Home Instead to perform reference-checking conversations with individuals whose names I provide, as well as with any other people whose names I have not provided.
I agree a telephone facsimile (fax) or xerographic copy of this Home Instead Senior Care Background and Reference Check Authorization, Consent, and Waiver (“Consent”) shall be considered as valid as the original consent. In the event of my employment by Home Instead, this authorization shall remain in effect for the duration of such employment.
I authorize and release individuals, business entities, references, current and former employers and their current and former employees, schools, credit bureaus, municipal, county, state and federal agencies and courts, to provide all information that is requested to Home Instead or its authorized agents. I further release and hold harmless all of the above, including Home Instead and its agents and employees, from any liability or claims arising from retrieving and reporting of information concerning me. I specifically waive any entitlement to be notified prior to the provision of such information by my references, former employers (including their employees, agents, representatives, or former employees), and any other individuals whom Home Instead may seek to contact.
Information contained in reports obtained by Home Instead in accordance with the above authorization may include information pertaining to your character, general reputation, police record, personal characteristics, and mode of living. You have the right to request that Home Instead completely and accurately disclose to you the nature and scope of all investigations requested. Such a request must be made in writing to the human resource department within a reasonable period of time after your application for employment is received.
I hereby acknowledge that I have read, understood and agree to the above Certification and Authorization, Consent and Waiver statements.
I UNDERSTAND THAT THIS APPLICATION IS NOT A CONTRACT FOR EMPLOYMENT
Electronic Signature Agreement
By selecting the "submit" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide disclosures or conditions constitutes your signature hereafter referred to as ("E-Signature"), as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature.