APPLICATION FOR EMPLOYMENT

1401 Pennsylvania Ave, Wilmington DE, 19806 - Suite 106

302-689-3240

EMPLOYMENT DESIRED

EDUCATION

TRADE SCHOOL

GRADUATE SCHOOL

PREVIOUS EMPLOYMENT

The provisions of 19 Del. C. $ 708 require that we obtain a service letter from you as an employer or former employer of a person below. The provisions of 19 Del. C. $708 also require any employer who receives a request for a service letter to provide the information on this form within ten (10) business days from receipt of the request. This law provides for penalties of $1,000 - $5000 for failing to disclose all applicable and available truthful information known to the employer.

The above-named person has applied for employment/licensure with our organization. The applicant indicated on his /her application that she was or is employed by you and has signed an authorization and release form that permits you to truthfully answer these questions without liability.

Background Check Centre (BCC) Consent From. The BCC process applies to any person who is employed to provide care or services :1) in any capacity, including as an employee, an agent, or an independent contractor, in a nursing facility, home agency, or similar facility licensed under Chapter 11 of Title 16 of the Delaware Code, or 20 as an employee of a hospice agency, a home care agency, or a personal assistance service agency ( home care agency ) licensed pursuant to 5122 (3) (m), (3) (0) and (3) (x) of Title 16 of the Delaware Code working in a private residence, or 3) temporary employment agencies providing individuals to work in the settings identified in 1 and 2 above

Three (3) different consents are required: One for the criminal history ( state and federal), one for the Child Protection Registry, and one for the transmission of drug test results, as required by 11 Del. C. 1142 and 1146.

For the purpose of this form, all of these work settings will be called entity/entities all persons or entities hiring a person for work are employers, all persons working will be called employees, regardless of whether self-employed, or employed by another, and the prospective employer will be the employer seeking to vet an employee before hiring, or as directed by statute.

I am seeking employment in an entity that requires that my application be processed through the BCC, 29 Del. C. $7970, The BCC contains information, derived from the state Bureau of Identification, regarding both my State of Delaware and federal criminal history record with the Division of Long-Term Care Residents Protection (DLTCRP) and the prospective employer. I understand that the criminal history Information provided to the prospective employer and DLTCRP is strictly confidential and that it may be used solely to determine my suitability for hiring and continued employment. I also understand that, if hired, I will be subject to a periodic update of my criminal history (Rap-Back), and I consent to that process.

If I am directed to work in an entity and the entity is not my employer, I consent to the sharing of my criminal history information by my employer with the entity where I am directed to work. If I am a student training in health care services and am directed to work in an entity as part of that training, I consent to the sharing of my criminal history information by the school I am attending with the entity where I am directed to work. If I am directed by my employer to work with a patient in the community, I consent to the sharing of my criminal history information with the patient, or the patient's surrogate or agent.

I am providing the information in the space below to facilitate the process of securing my criminal history for the BCC. The information I have provided is true and accurate. I have been informed that failure to provide accurate information could result in a civil penalty of not less than $1,000 or more than $5,000 for each violation.

I hereby grant the employer or prospective employer a full release from liability related to the procurement or evaluation of my criminal history now, or in the future, if additional information is provided through the Rap-Back. I also grant the employer or prospective employer a full release from liability related to the sharing of my criminal history with an entity where I have been directed to work.

I further understand that any employment before the receipt of the criminal history record review is conditional and that such conditional employment is limited to 60 days.

I hereby authorize the Delaware Department of Service for Children, Youth, and their Families to provide the below-named agency/ organization with all substantiated cases of child abuse or neglect concerning me contained in the Child Protection Registry. I further release the Delaware Department of Services for Children, Youth and Their Families, its officers and employees from any and all claims arising out of oe in any way connected to the release or dissemination of any information concerning me.

I am required to submit to drug testing as part of the employment process (11 Del. C. $1142 and $1146)

The BCC will electronically transmit the drug test results directly from the testing laboratory to the prospective employer if the testing laboratory is connected to the Delaware Health Information Network (DHIN). If the testing laboratory is not part of the DHIN, the results will be transmitted to the prospective employer directly by whatever methods are mutually agreed upon. The drug test results shall be used solely to determine my suitability for employment. The prospective employer is required by law to maintain the confidentiality of the results.

I consent to the release of the drug test results to the prospective employer.

4. SERVICE LETTERS

This form is provided by Delaware Health and Social Services (DHSS) for an employee whose employment is terminating and who may choose to stay on the Master List for Up to 3 years post-fingerprinting in order to facilitate re-employment.

The Master List is a list maintained by the Background Check Center (BCC) for each employer. The list contains the names of all persons who:

*Are employed in the employer's facility as defined in 16 DeL. C. 1141 (b) (5);

*Are employed by a temporary employment agency, home health or personal care agency, or any other entity to work in a facility or in a private residence as defined in 16 Del. 1145 (b) (8);

*Are self-employed individuals working as an independent contractor for the employer;

*Are listed on an employer's Master List and wish to stay on the Master list to facilitate rehire and have consented to stay on the Master List for not more than 3 years.

All persons working in facilities are required to be on the Master List of the BCC.

The BCC automatically conducts a Rap-back on all employees listed on the Master List. The Rap-back process will provide the Division of Long-Term Care Residents Protection (DLTCRP) with information regarding any new arrest or conviction in the state. The DLTCRP will determine, at its discretion, and depending on the nature of the alleged crime, whether or not to inform the employer of the interest. The DLTCRP will monitor the charge until there is a disposition. When the disposition is known, the DLTCRP will inform the Employer of the outcome

An employee whose employment is terminating may, at the time of separation, execute this Master list retention form in order to remain on the Master List of the BCC. The consent period can be up to 3 years from the date last fingerprinted. Consent cannot extend beyond 3 Years from the date last fingerprinted.

An employee whose employment is terminated may remain on the Masters list to facilitate re-employment by the same or another facility up to 3 years beyond the date the individual was last fingerprinted.
When that date is reached, the employee will automatically be removed from the BCC Master list without further action by the employer.

I consent to remain on the Master List until the following date or until my fingerprint date expires, whichever date comes first.

Background Check Center (BCC) Consent Form

ADDRESS

BACKGROUND CHECK CENTER (BCC) CONSENT FORM - APPLICATION RIGHT

FORM OF LOYALTY AND CONFIDENTIALITY AGREEMENT

1. Definitions: "Customer" means a person or entity that has an ongoing business relationship or prospective business relationship with the company before any act of prohibited interference, and (i) that did business with a facility, division, or portion of the company's business that Employee's supervision in the preceding two years, or (ii) had materials contact with Employee or a person under Employee's supervision in the preceding two years. A "Competing Business" is a person or entity that is in the business of providing a Conflicting Product or Service. A "conflicting product or Service" is a product or service that would displace a product or services that the Employee assist the company in developing, selling, distributing, servicing, or otherwise providing to the Company's customers or receives Confidential products and services that company is information about within the preceding two (2) years. In the business of providing to its customer include, without limitation, renting or leasing household durable goods, servicing and reparing durable goods, and providing financial services to customers, including but not limited to deferred deposit lending, short-term consumer loans, and/or check cashing.

2. Duty of Loyalty. Employee agrees to avoid conflicts of interest and promptly inform the company of any business opportunities that are related to the Company's line of business. Employees will avoid competing with the company, setting up a business to compete with the company, or undertaking other disloyal acts while employed with the Company.

3. Restriction on Interfering with Employee Relationships. During employment with the Company, and for two (2) years thereafter, Employee will not, either directly or indirectly, (a) solicit, induce, or encourage any employee and/or customer of the Company to leave the Company, or (b) help another person or entity to hire away an employee of the Company to leave the company unless such activities is expressly authorized by a supervisor of Employee on behalf of the Company. Where required by law, the foregoing restriction will only apply to employees that Employee, worked with, supervised, or helped manage, within the last two years of Employee's employment.

4. Confidentiality and Business Interest. The parties agree to the following to protect the Company's legitimate business interests.

   a. "Confidential information" means the Company's information retained by the Company that the Company has not authorized for disclosure to the public. The parties agree that, without limitation, some examples of the Company's Confidential Information are :

   • Business record and plans

   • Technical information

   • Products

   • Software

   • Financial Data

   • Clients Information

   • Customer Leads or prospects

   • Contractor relationships or key vendors- And other proprietary information

     Additionally, the Company's non-public compilations of otherwise available information that attain greater value or utility because of time and expense invested in a unique compilation, analysis, or formatting will be considered Confidential Information.

     Information disclosed to the general public by the Company through proper means is not considered Confidential Information

     5. Merger of the Entire Agreement

     This Agreement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes any prior understanding and agreements between them with respect to the subject matter of this Agreement. This Agreement cannot be modified except by a written agreement signed by both parties.

     IN WITNESS WHEREOF, the parties have caused this Agreement to be executed by their duly authorized representatives effective as of the Effective Date.

I understand the photograph (s) or video or audio recording (s) taken of me by agents, employees or representatives of The Regents of Reliable Aid Inc., shall be used in connection with the Company's dissemination of information by its public service and Health Care programs to the general public. I hereby irrevocably authorize Reliable Aid Inc. to copy, exhibit, publish or distribute any and all such images and audio of me or wherein I appear, including composite or artistic forms and media, for purposes of publicizing Reliable Aid Inc. programs or for any other lawful purpose. In addition, I waive any right to inspect or approve the finished product, including a written copy, wherein my likeness appears. As a result, I hold harmless and release and forever discharge Reliable Aid. Inc from all claims, demands and causes of action which I, my hairs, representatives, executors, administrators or any other persons acting on my behalf of my estate have or may have by reasons of this authorization. I hereby release all my rights and ownership to Reliable Aid Inc. of any photograph (s) or video or audio recording (s) taken of me by agents, employees or representatives of The Regents of Reliable Aid Inc.