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Job Application Agape HealthCare Solutions. 5578 Cathers Creek Dr. Hiram, Ga. 30141

Please Print All Information ______Date

______Last Name, First Name, Middle Initial

______Home address (Number and street or rural road) City, State, and ZIP Code

Telephone Numbers: ______(if applicable) i.e. home/mobile

Position Applied for: ______Certification # (if applicable): ______

Shifts willing to work: (check all that apply):  First Shift  Second Shift  Third Shift

Salary or Hourly Rate expected: ______

Do you have your own transportation?  Yes  No  Public Transportation

Are you currently employed?  Yes  No

May we contact your present employer?  Yes  No

Are you 18 years or older?  Yes  No

Are you prevented from lawfully becoming employed in this country due to Visa or Immigration status?  Yes  No (Proof of citizenship or immigration status is required upon employment)

You are available to work:  Full Time  Part Time  Temporary

Date you can begin working: ______

Have you been convicted of a crime within the last seven years? (Other than minor traffic violations, a conviction will not  Yes  No necessarily disqualify an applicant from employment).

If yes, please explain: ______

______

Emergency contact: Name ______Number ______Relation ______

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Job Application Agape HealthCare Solutions. 5578 Cathers Creek Dr. Hiram, Ga. 30141 EDUCATION: School Name and Address Credits Earned Major Diploma/Degree Date of Gradutaion High School:

College:

Technical/Other:

List present and past employment below, beginning with your most recent employer. All times must be accounted for whether employed or not. Attach an additional sheet if necessary.

Name and Address of From To Describe in Beginning Ending Reason Name, Title and Phone Company and Type of detail work Wage Wage for Number of your supervisor Business MO YR MO YR you did and Leaving your title

PERSONAL REFERENCES: Name: Address: Phone: Company: Relationship: Years Known:

Job Application Agape HealthCare Solutions. 5578 Cathers Creek Dr. Hiram, Ga. 30141 AFFIRMATIVE ACTION VOLUNTARY INFORMATION

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We consider all applicants for positions without regard to race, color, religion, sex, national origin, citizenship, age, and mental or physical disabilities. We also comply with all applicable employment practices and do not discriminate on the basis of any unlawful criteria.

This form is to be completed by the applicant on a voluntary basis and is not for interview purposes. It is to be filed separately from the application.

In an effort to comply with requirements regarding government record keeping, reporting, and other legal obligations that may apply, we ask that you complete this applicant data survey form. Providing this information is Strictly Voluntary. Failure to provide it will not subject you to any adverse personnel decision or action. Be advised that this survey is not a part of your official application for employment. It will not be used in any hiring decision. The information contained will be kept confidential.

Position Applied for: ______Name: ______Gender: ______

Please check one of the following Equal Employment Opportunity Identification Groups:  American Indian/Alaska Native  Black (not of Hispanic origin)  White (not of Hispanic origin)  Asian/Pacific Islander  Hispanic  Decline______

How Did You Find Out About This Job?  Walk-In  School/College  Agency  Recruiter  Civic Organization  Government Agency  Decline______

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Applicants Signature: Date:

Job Application Agape HealthCare Solutions. 5578 Cathers Creek Dr. Hiram, Ga. 30141 CONSENT AND RELEASE

I, ______as an employee of Agape Home Health Care, Inc. (the Company) hereby acknowledge that the Company’s policy requires me to submit to a breathalyzer analysis and/or a sample of my urine and/or blood for chemical or other analysis after any and all injuries or at any time at the discretion of the company.

I further understand that the purpose of this analysis is to determine or rule out the presence of non-prescribed or prohibited dangerous controlled substances on my breath, in my urine and/or blood. I hereby freely and voluntarily consent to this request for a breath, urine and/or blood specimen and agree to participate in the testing program.

To the fullest extent permitted by law, I hereby and herewith release the “Company:, its employees, agents, and contractors from any and all liability whatsoever arising from this request for a breath, urine, and/or blood sample, and from decisions made concerning my continuation of employment based upon the results of the analysis.

Any delay of or interference with the testing process shall be treated as a positive test under the “Company” policy. I agree to cooperate in all respects as to the testing program.

I further acknowledge that the “Company” has provided me with the opportunity to ask questions related to its drug testing program and that all my inquires have been answered.

I understand that it is the responsibility of the employee to report any injury to the “Company” immediately.

THE POSITIVE RESULTS OF ANY TEST UNDER THIS POLICY MAY AFFECT THE EMPLOYEE’S ELIGIBILITY FOR WORKERS COMPENSATION BENEFITS.

THE REFUSAL TO SUBMIT TO ANY TEST UNDER THIS POLICY MAY AFFECT THE EMPLOYEES’ ELIGIBILIGY FOR WORKERS COMPENSATION BENEFITS.

______Date:

______Employee’s Signature: Company Witness: