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CERTIFICATION AND RELEASE

I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete, true and accurate to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my engagement with Happy at Home - In Home Care Inc. I authorize Happy at Home - In Home Care Inc. and/or its agents, including consumer-reporting bureaus, to verify any of this 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 background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release Happy at Home - In Home Care Inc. from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during engagement with Happy at Home - In Home Care Inc. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during my engagement with Happy at Home - In Home Care Inc. I understand that this application is not a contract of employment. My engagement with Happy at Home - In Home Care Inc. is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if retained by Happy at Home - In Home Care Inc., the work relationship between Happy at Home - In Home Care Inc., and myself is at-will, so that both Happy at Home - In Home Care Inc. and I remain free to choose to end our work relationship with proper notice per the Caregiver/Independent Contractor Agreement. In order for you to receive client referrals about your work proper notice to leave Happy at Home - In Home Care Inc. must be given. Any changes in this work engagement must be in writing. I understand due to the nature of this business/industry, no guarantee can ever be made as to the schedule hours or the amount of hours assigned to work. My signature below acknowledges that I have read, understand, and agree to the above disclosure. I furthermore understand that due to the nature of the business, no amount of work can be guaranteed. I understand that this application is not a contract for employment.


By typing your full name and providing the date below you are electronically signing this document. The name listed here will be considered the legal and binding mark of the applicant completing this application.

Check this box and type in your Full Name (First and Last) and fill in the date if you fully understand and agree to the terms above.

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