A background screening via the FCSR must be performed prior to the first day. Please disclose all criminal convictions, findings of guilt, and pleas of nolo contendere or provide a statement that there is no record of such background. Failure to disclose any criminal information is a violation of the law. All convictions will be identified by the FCSR, including convictions more than 10 years ago. If the answer is yes, indicate with an explanation.

I certify that the facts contained in this application are true and completed to the best of my knowledge and understand that if hired falsified statements on this application shall be grounds for employment termination. I authorize investigation of all statements contained herein and the reference and work history listed above to give you any and all information concerning previous work history, criminal records, background, and any pertinent information they may have personal or otherwise and release the company from all liability for any damage that may result from utilization of such information.

I give Unique Inventive Strategies for Home Care consent to conduct a pre-employment FCSR, Criminal Record and EDL Check. I also Unique Inventive Strategies for Home Care consent to a closed record check pursuant to Section 610.120, RSmo. I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.

I authorize investigation of all statements contained herein and the references and corporations, educational institutions, law enforcement agencies, state agencies military services, D.M.V. records, and former employers to release any information including my skills, background, character, and personal reputation with regard to my suitability for employment with Unique Inventive Strategies for Home Care.

I agree to waive any claim or cause of action relating to such release and promise to defend and hold harmless those entities listed above, their officers and employers and the Unique Inventive Strategies for Home Care, its officers and employers from any claim or loss arising from such release. It is my intention that any copy of this authorization be as effective as the original.

I give Unique Inventive Strategies for Home Care permission to verify employment, professional, and personal references.

I agree to maintain confidentiality with any consumer(s) that offers me a position as their personal aide attendant(s) and any information I may have access to regarding their circumstances, medical conditions, family situations, financial situations, and/or any other information I might come in contact with.

I have been instructed in maintaining the confidentiality of all medical information.

I have been advised that, unless I am reporting information regarding a consumer to my supervisor(s) or other relief personnel, medical information may not be discussed with anyone either inside or outside the office.

I have also been instructed in procedures for reporting suspected abuse and neglect and will follow such procedures if any such situations would arise.

It is my understanding that casual discussion of confidential information is cause for dismissal.

My signature assures that I have read and understood all the information above and that my answers reflect the truth.