APPLICATION FOR EMPLOYMENT

FULL NAME

ADDRESS

ADDRESS

4. During the past 5 years:

Applicant understands that this is an Equal Opportunity Employer and committed to excellence through diversity. In order to ensure this application is acceptable, please print or type with the application being fully completed in order for it to be considered.

Please complete each section EVEN IF you decide to attach a resume.

I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information in my application or interview may result in my employment being terminated.

I hereby affirm that the information provided on the application and accompanying resume, if any, is true and complete to the best of my knowledge. I also agree that my falsification or omission of required information may disqualify me from further consideration for employment and may be considered justification for dismissal from employment if discovered at a later date.

I authorize a thorough investigation of my past educational and employment activities, agree to cooperate in such investigation, and release from all liability or responsibility all persons and concerns requesting or supplying information. I understand and agree that Global Healthcare Agency, LLC may contact any or all past employers pursuant to this investigation.

It is the policy of Global Healthcare Agency, LLC not to discriminate in hiring and employment, in accordance with the requirements of all applicable State and Federal laws, on the basis of race creed, religion, national origin, sex, citizenship status, age or the presence of a qualified mental, physical or visual handicap. I hereby agree to submit to any lawful drug, integrity and skill testing that may be required as a condition of my employment or continued employment and understand that unless otherwise prohibited by law, refusal to submit to such testing during the course of my employment may result in dismissal.

I understand that this application is valid for 90 days only. I also understand that if I am employed, I agree to accept the employment conditions of the company. In consideration of employment, I agree to conform to the policies and procedures of Global Healthcare Agency, LLC and understand that the company may change these from time to time without notice; and that employment may be terminated at any time with or without cause or any notice at the option of either the company or me. I understand that this application is not intended to be a contract for employment now or in the future. I understand that no company manual or document is intended to change this, and no manager or representative of Global Healthcare Agency, LLC other than the executive Director has any authority to enter into any agreement for employment.

I, hereby authorize and agree that Global Healthcare Agency, LLC will conduct the appropriate inquiries to determine my eligibility for my employment on behalf of the company. I fully understand that these inquiries may include, but are not limited to, criminal record checks,driving records, credit reports and interviews.

I agree to indemnify and hold Global Healthcare Agency, LLC and its agents harmless against any and all liability, cost and expenses, including attorney’s fees, occasioned by claims or suits for loss or damage arising out of the reasonable and lawful acts.

This authorization is valid for a period of 30 days

Address of Former Residences: (If lived at present residence less than seven years):

Global Healthcare Agency, LLC, has my authorization to check my references

PLEASE VERIFY EMPLOYMENT DATES:

Section s32.1-162.9:1 of the code of Virginia requires that any applicant for employment with a licensed home care organization provide the Commissioner’s representative with a sworn statement or affirmation disclosing (1) whether the applicant has a criminal conviction or is the subject of any pending criminal charges within or outside The Commonwealth of Virginia, and (2) whether the applicant has been thesubject of a found complaint of child abuse or neglect within or outside the Commonwealth of Virginia.

Any person making a materially false statement on this from shall be guilty of a Class I misdemeanor.

Further dissemination of the information provided on this form is prohibited other than to the Commissioner’s representative or a federal or state authority of court as many be required to comply with an express requirement of law for such further dissemination.

5. I hereby affirm that the information provided on this form is true and complete. I understand that the information is subject verification.

Global Healthcare Agency, LLC does not permit employees on company time to talk on their cellular phones while driving a vehicle. This is very dangerous and should be avoided any time. It is mandatory that I must pull over and stop my vehicle each time I conduct agency business per cellular phone.

The agency is not responsible for any moving violations, accidents or other incident that may occur while I am using my cellular phone and driving.

I have read and understand the above information of the agency regulation regarding cellular phone use, and I will comply.

Have you noticed any of the following?

I understand that I am responsible for following this Confidentiality Policy Agreement & The Guidelines, Both Written and Verbal.

Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application.

Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint-based background checks. Your fingerprints and associated information/biometrics may be provided to the employing, investigating, or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI.

Routine Uses:During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

Applicant’s Rights: Your fingerprints will be used to check the criminal history records of the FBI and the Central Criminal Records Exchange (CCRE) of the Virginia State Police. You have the right to expect that officials receiving the results of the criminal history record check will use it only for authorized purposes and will not retain or disseminate it in violation of state or federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council. If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this process may be obtained at https://www.fbi.gov/services/cjis/identity-history-summary-checks. If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may send your challenge directly to the FBI. The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenged entry. Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through 16.34.) You may obtain a copy of your Virginia Criminal History by submitting form SP-167, available at https://vsp.virginia.gov/services/criminal-background/ to the CCRE. You may challenge the accuracy or completeness of a Virginia criminal history record through the CCRE Expungement/Record Challenge Section, which can be reached at (804) 674-6723 for further information about this process.