Applicant Information

Education

References

Please list three professional references.

Previous Employment

Military Service

Disclaimer and Signature

I certify that my answers are true and complete to the best of my knowledge.

If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Employee Reference Sheet

I , authorize the release of my work history and job reference to Miracle Home Care.

Employer Completes Below

Kansas 3rd Party Consent Form

I hereby authorize Miracle Home Care obtain my vehicle registration and/or driver's license record information including my personal informationon those records.

Background Check Disclosure and Authorization

Pursuant to the federal Fair Credit Reporting Act, I hereby authorize Miracle Home Care and its designated agents and representatives to conduct a comprehensive review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion,reassignment or retention as an employee. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: verification of Social Security number; current and previous residences; employment history, including all personnel files; education; references; credit history and reports; criminal history, including records from any criminal justice agency in any or all federal, state or county jurisdictions; birth records; motor vehicle records, Including traffic citations and registration; and any other public records.

I , authorize the complete release of these records or data pertaining to me that an individual, company, firm, corporation or public agency may have. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me to furnish Miracle Home Care or its designated agents with any and all information in their possession regarding me in connection with an application of employment. I am authorizing that a photocopy of this authorization be accepted with the same authority as the original.

I understand that, pursuant to the federal Fair Credit Reporting Act, if any adverse action is to be taken based upon the consumer report, a copy of the report and a summary of the consumer's rights will be provided to me.