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.

BACKGROUND CHECKS: In compliance with Colorado State regulations, upon extension of an offer of employment, this applicant agrees to submit to a background check (at the Home’s expense) from the Colorado Bureau of Investigation and from one’s previous County/State(s) of residence/employment if your residency in Colorado is less than 3 years from the date of application, as a criminal background investigation. This applies to all positions. Refusal may result a rescission of the offer of employment. 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 below listed crimes: (1) Any crime pertaining to elder abuse (2) Any felony for which the individual has not yet completed the sentence. Further, Further, I 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 below listed crimes: (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.

PRE-EMPLOYMENT DRUG SCREENING: Upon extension of an offer of employment, this applicant agrees to submit to pre-employment drug screening (at the Home’s expense). Refusal may result a rescission of the offer of employment. ADULT PROTECTIVE SERVICES CHECK: Upon extension of an offer of employment, an applicant who is being hired to provide direct-care (nursing staff and nursing aides), agrees to submit to a Colorado Adult Protective Services data system (CAPS) check (at the Home’s expense). Refusal may result a rescission of the offer of employment.