This information is being requested as part of a background study initiated by G&H of Greater Minnesota, Inc. (dba: 4U Home Health Care) and 2Care4U, LLC, which is required by the Minnesota Department of Human Services (DHS), to determine employment eligibility.

I know that state and federal privacy laws protect my records. I also know that I do not have to consent to the release of this information, however if I do not consent, the required background study process will not be completed.

If you answer YES to any of the questions below, give an explanation in the space provided or as an attachment. The explanation should include, but is not limited to: State and/or jurisdiction, nature of complaint, dispostion of complaint (i.e. "dismissed for insufficient evidence"), date of dispostion, and attached copies of any correspondence received with regard to the complaint.

Please list your work experience for the past 3 years beginning with your most recent/current job held. If you were self-employed, give company name. Attach additional sheets if necessary.

In exchange for the consideration of my job application by G&H of Greater Minnesota Inc. and/or 2Care4U LLC (hereinafter called "the Company"), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the postion applied for or any other position, and regardless of the contents of employee handbooks, policy and procedure statements, manuals, benefit plans, and the like as they may exist form time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain the employee of the Company, or other wise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by written instrument signed by the President/Vice President of the Company. Both the undersigned and the Company may end the employment relationship at any time, with or without notice or cause. I undestand that the Company may unilaterally change or revise their handbooks, policies and procedures, and benefits at any time without notice.

I authorize the investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts call for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, present and previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contact.

I also understand that (1) the Company has a drug and alcohol policy that may require pre-employment testing as well as post-employment testing; (2) consent to and compliance with such policy is a condition of employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of a job-related physical examination.

I further understand that my employment with the Company shall be probationary for a period of 90 days or 520 hours, whichever comes first, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at-will for any reason by either party.