I hereby declare that I can perform the job-related functions applied for in this application. I further declare that the answers to the questions on this application are correct and that any misstatement of fact or omission could be cause for dismissal or rejection. I agree that any employment arrangement entered into is based upon the truthfulness of the statements that I have made herein. I understand I am a "Conditional Employee" until Sanzie Healthcare services,Inc. has received verification of a satisfactory criminal background check and I have successfully obtained a Class II finger print card.

I understand that if employed, if medication is prescribed by a doctor for me to take, and the medication prescribed may impair my performance of my job related duties, or endanger other workers, I am to so notify management of the specific medical problem and the exact drug that has been prescribed, prior to working any job assignment.

I understand that if employed, I will be to maintain current CPR and First Aid certifications while employed by Sanzie Healthcare services,Inc. and am responsible for the costs incurred thereof. In addition, I will be to maintain current and furnish verification for a Fingerprint Card, TB Test results, personal automobile insurance (if driving any vehicle for a client of for SHCS), and a current copy of my driving record.

I hereby authorize Sanzie Healthcare services,Inc. (SHCS) to seek references from previous employers listed on this form, and to obtain a report from a government-reporting agency to be used for employment purposes. I authorize the references and previous employers listed to give SHCS all information and opinions concerning me and my previous employment. I release all such parties from any liability which may arise from furnishing such information to SHCS including, but not limited to, any liability for defamation or invasion of privacy. A photocopy of this consent and release will be valid as an original even though the photocopy does not contain an original writing of my signature. I certify that I have read, fully understand and agree with the foregoing certification statement. This authorization will expire one year after the date signed and noted below.

By entering my name and today's date below and submitting this form, I am indicating that I am electronically signing this form and have read the above statements; I have correctly filled out the Application to the best of my knowledge; and understand the content, intent and terms of this Application.