List names of employers in consecutive order with present or last employer listed first. Account for all periods of time, including military service and any period of unemployment. If self-employed, give form name and supply business references. Give month and year.

Not relatives or former employers.

I certify that the answers given to me by the foregoing questions and statements are true and correct without consequential omissions of any kind whatsoever. I agree that the company shall not be liable in any respect if my employment is terminated because of falsity of statements, answers, omissions made by me on this questionnaire. I also authorize the companies, schools or persons named above to give any information regarding my employment, character and qualifications. I hereby release said companies, schools or person from any liability for any damage for issuing this information. I understand that any misleading or incorrect statements may render this application void and if employed would be cause for termination. I understand there is no express or implied contract of employment and if employed I have been hired at the will of the employer and my employment may be terminated at any time; and without cause, the employer's only obligation being to pay salary or wages due and owing at the time of termination. Finally, I understand that all company property must be returned and any indebtedness must be paid before my termination. I authorize the company to deduct all monies due and owing the company from my last paycheck.

In compliance with Colorado state regulations, persons applying for a position at The Myron Stratton Home will agree to submit to a name search from the Colorado Bureau of Investigation and from one's previous state of residence if your residency in Colorado is less than 2 months from the date of application, as a criminal background investigation. This applies to all positions. I also understand that my employment with The Myron Stratton Home is contingent upon the fact that I have never been convicted of or have never had a deferred judgment agreement for any of the following crimes: (1) Any crime pertaining to elder abuse (2) Any felony for which the individual has not yet completed the sentence. Further, the Home shall terminate an employee who has been convicted or has entered into a deferred judgment agreement within the ten years prior to employment for any of the following: (1) Any felony related to the sale of a controlled substance (2) Any conviction or deferred judgment agreement for any crime which adversely reflects upon the character and suitability of the Home or indicates that the individual may post a threat to the health, welfare, and safety of the residents.