APPLICANT CERTIFICATION, ACKNOWLEDGEMENT AND DISCLAIMER
I certify that this application contains no willful misrepresentation or falsification and that the information given by me is true and complete to the best of my knowledge and belief. I am aware that should an investigation, at any time, disclose any such misrepresentation, omissions of fact, incomplete answers in any application document or falsification as to a material fact, my application will be rejected. I further understand that if employed and subsequently misrepresentations and/or omissions are discovered, I will be terminated from my position.
I understand due to the vulnerability of the clients this agency serves, I must be registered with the Family Care Safety Registry and am responsible for correcting any errors or inaccurate information disclosed to this agency by the Registry. I further uderstand that should information about me appear on the Registry at any time, before or during any employment with this agency, my application my be rejected and/or my employment may be suspended, terminated or both and continued employment if any, will be dertermined after evaluating the information on the Registry and the issuance of a "Good Cause Waiver". I am responsible to apply for a "Good Cause Waiver" if necessary.
I EXPRESSLY AGREE AND UNDERSTAND THAT, IF EMPLOYED, MY EMPLOYMENT IS NOT FOR A SPECIFIC TERM, IS BASED ON MUTUAL CONSENT AND MY BE TERMINATED BY ME OR THE AGENCY WITH OR WITHOUT NOTICE OR CAUSE AT ANY TIME. I FURTHER UNDERSTAND THAT NO ORAL PROMISE, AGENCY POLICY, CUSTOM, BUSINESS PRACTICE OR OTHER PROCEDURE (INCLUDING THE BASIC EMPLOYMENT POLICIES, PERSONNEL OR DEPARTMENTAL HANDBOOK, OR ANY PERSONNEL MANUALS) CONSTITUTES AN EMPLOYMENT CONTRACT OR MODIFICATION OF THE AT-WILL EMPLOYMENT RELATIONSHIP BETWEEN ME AND THE AGENCY. I ALSO UNDERSTAND THAT THIS ASPECT OF MY EMPLOYMENT MAY NOT CHANGE ABSENT AN INDIVIDUAL WRITTEN AGREEMENT SIGNED BY BOTH ME AND THE EXECUTIVE DIRECTOR OR AUTHORIZED REPRESENTATIVE OF HOMECARE OF MID-MISSOURI.
I understand I may be required to maintain a reliable and continuous method of transportation necessary to perform the duties of my job, if hired, and to provide notarized documents granting me permission to use vehicles I do not own and to provide proof of insurance for any vehicle I may drive. I further understand I may be required to take job related tests and drug and/or alcohol tests during my employment, if hired.
APPLICANT'S SIGNATURE DATE
AUTHORIZATION FOR EMPLOYMENT
I hereby authorize my previous employers or any education institutions I have attended to release to HomeCare of Mid-Missouri's authorized representative(s) any information they may have regarding my character, academic record, employment history or criminal background, whether on record or not. I also authorize any enforcement agency, Department of Family Services, Missouri Department of Health and Senior Services (including the Employee Disqualification List), the Missouri State Highway Patrol Criminal Records Division, Missouri Family Safety Care Registry or other pertinent regulatory agencies to release and disclose any records pertaining to my convictions (without further notice to me) and for HomeCare of Mid-Missouri to copy, examine and/or receive any records pertaining to me regarding convictions and reports. By authorizing the above, I agree to hold harmless HomeCare of Mid-Missouri, including any individual, partnership, corporation, educational institution or agency, its officers, agents and employees from any liability for any damage whatsoever for issuing such good faith reference information.
APPLICANT'S SIGNATURE DATE