PERSONAL INFORMATION

Last Name           First Name  
Middle Intial    

Social Security     Driver's License 

Home Address       City  
State                       Zip

Email              

EMPLOYMENT DESIRED

Position          
Anticipated Start Date
Desired Salary
Full-Time     Part-Time     Per-Diem     Sub-Contractor/1099

Are you currently employed? Yes   No

May we inquire your present employer? Yes   No

EDUCATION

Elementary School    Degree 
City, State    Years Attended    Did you graduate?  Yes   No

High School     Degree 
City, State    Years Attended    Did you graduate?  Yes   No

College   Degree 
City, State    Years Attended    Did you graduate?  Yes   No

Post Graduate   Degree 
City, State    Years Attended    Did you graduate?  Yes   No

Certification Training, or Subject of Special Study or Research   Degree 
City, State    Years Attended    Did you graduate?  Yes   No

PROFESSIONAL LICENSING

Professional License Number  

MILITARY SERVICE RECORD

Branch of Service  
Type of Discharge     Discharge Date
Rank at Discharge  

EMPLOYMENT VERIFICATION

ARE YOU LEGALLY ENTITLED TO WORK IN THE UNITED STATES? Yes   No

Rehab Matters Home Health, Inc. will require verification of employment eligibility as required by law including completion of an I-9 form.

WORK EXPERIENCE

1. Name of Present or Last Employer  City  State
Name of Supervisor  Job Title
Start Date (Mo/Yr)    Departure Date (Mo/Yr)
Starting Salary   Final Salary
Explain reasons/circumstances for changing or wanting to change jobs

2. Name of Present or Last Employer  City  State
Name of Supervisor  Job Title
Start Date (Mo/Yr)    Departure Date (Mo/Yr)
Starting Salary   Final Salary
Explain reasons/circumstances for changing or wanting to change jobs

3. Name of Present or Last Employer  City  State
Name of Supervisor   Job Title
Start Date (Mo/Yr)    Departure Date (Mo/Yr)
Starting Salary   Final Salary
Explain reasons/circumstances for changing or wanting to change job

4. Name of Present or Last Employer  City  State
Name of Supervisor  Job Title
Start Date (Mo/Yr)    Departure Date (Mo/Yr)
Starting Salary   Final Salary
Explain reasons/circumstances for changing or wanting to change jobs

5. Name of Present or Last Employer  City  State
Name of Supervisor  Job Title
Start Date (Mo/Yr)    Departure Date (Mo/Yr)
Starting Salary   Final Salary
Explain reasons/circumstances for changing or wanting to change jobs

REFERENCES

Name      Title
Address   Phone Years Known

Name      Title
Address   Phone Years Known

Name    Title
Address   Phone Years Known

CERTIFICATION OF ESSENTIAL JOB FUNCTION

INITIALS
I have been advised of the essential job functions for the position for which I am applying.

INITIALS
There is nothing that would prevent me from performing the essesntial duties of the position for which I am applying.

HAVE YOU EVER BEEN CONVICTED OF A FELONY? Yes No

CERTIFICATION AND ACKNOWLEDGEMENT

I certify that all information submitted in this application form, resume or interview is true and complete and that I have not knowingly withheld, nor will I withhold, any information that would affect my application for employment. I understand that Rehab Matters Home Health, Inc. is under no obligation to consider or reconsider thai application at any time and that acceptance of my application does not constitute an offer of employment. I also understand and agree that: (Please initial each item)

1. Inquiries may be made with my previous employers or others who may have knowledge of me, and schools or colleges. I authorize any such person or agency to give you any and all information concerning my previous education and employment, including but not limited to, an assessment of my job performance, ability and fitness and/or any other information they may have, personal or otherwise, and release all parties from any and all liability, claims, or damages that may directly or indirectly result from furnishing same.

2. Prior to my beginning work or during my employment, Rehab Matters Home Health, Inc. reserves the right to conduct a criminal background check for employment purposes. I understand that a prior criminal conviction willnot necessarily make me ineligible for employment. I hereby consent to a criminal background check and authorize the release of the report and any other information to the company. I hereby release the company, its divisions, affiliates, and associates, and anyone acting on their behalf from any and all claims or liabilities of any nature arising from or related to the preparation of the information contained in the criminal background reports, and the disclosure of such information for employment purposes.

3. Prior to my beginning work or during my employment, Rehab Matters Home Health, Inc. reserves the right to obtain consumer reports as part of Rehab Matters Home Health, Inc.’s evaluation of my job
application/employment. The reports may include my professional license, health certificates, driving record, an assessment of my insurability under Rehab Matters Home Health, Inc.’s insurance coverage’s or consumer reports. I hereby release the company, its divisions, affiliates, and associates, and anyone acting on their behalf from any and all claims or liabilities of any nature arising from or related to the preparation of the information contained in the consumer reports, and driving records, and all other reports about me from time to time, as it deems appropriate, to evaluate my insurability, eligibility or for other permissible purposes and the disclosure of such information for employment purposes.

4. I understand that as a condition of my employment, I must take and pass a pre or post employment urine and/or blood test at authorized threshold levels for any and all of the drugs or alcohol listed by Rehab Matters Home Health, Inc.’s Drug Free Workplace Policy.

5. I further understand, subject to confidentiality constraints and rights of appeal granted by State and Federal law, if the results of my pre or post employment drug and/or alcohol tests are POSITIVE (indicating substance abuse) and are received by Rehab Matters Home Health, Inc. prior to or during your employment with Rehab Matters Home Health, Inc. notwithstanding any other disciplinary provisions contained in the Rehab Matters Home Health, Inc. Drug-Free Workplace Policy statement, I will be terminated for cause and Rehab Matters Home Health, Inc. may seek to deny any employment benefits I might attempt to obtain.

6. Prior to beginning work with Rehab Matters Home Health, Inc. I will be required to sign a Non-Discrimination/Non-Retaliation Policy Agreement.

7. Prior to beginning work with Rehab Matters Home Health, Inc. I will be required to sign a Confidentiality/ Trade Secrets and Non- Solicitation Agreement.

8. I represent and warrant to Rehab Matters Home Health, Inc. that I am under no contractual or other restriction or obligation which would prevent me in any way from working with Rehab Matters Home Health, Inc. including but not limited to, a covenant not-to-compete, confidentiality agreement, and/or trade secret agreement. If I believe that I am presently under such contractual obligation, I will provide a copy of such agreement to Rehab Matters Home Health, Inc.

9. I also understand and agree that no representative of Rehab Matters Home Health, Inc. has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and approved by the Governing Board of Rehab Matters Home Health, Inc.

10. If employed, I understand and agree that my employment is "at-will" and may be terminated with or without cause or notice at my option or at the option of Rehab Matters Home Health, Inc.

11. I understand that any misrepresentation, falsification or omission of this application shall be sufficient reason for refusal or dismissal of my employment. I hereby authorize investigation of all matters contained in this application and agree that if the results of such investigation are not satisfactory, any offer of employment made by Rehab Matters Home Health, Inc. or any subsidiary hereinafter referred to as Rehab Matters Home Health, Inc. may be withdrawn, or my employment with Rehab Matters Home Health, Inc. may be terminated immediately.