Become a Caregiver – Iowa

Education

Please list ALL education, including high school, starting with the highest year completed.

Personal References

Please do not include relatives.

Employment History

Please list all employers. Begin with most recent or present.

Employer 1

Employer 2

Please Read Carefully

I hereby authorize the release, to Caretech, Inc., the results of my medical examination, including drug
screening test results, for internal use by Caretech, Inc. to evaluate my suitability for employment. I
also authorize any educational institutions I have attended, previous and current employers, law
enforcement agencies, and any others who possess information about me to release any and all such
information to Caretech, Inc. In a manner consistent with this authorization, I also hereby release
Caretech, Inc. from any and all claims or causes of action, in law or equity, which I might otherwise
have, arriving from the transmittal of such information to Caretech, Inc. and its use of it.

I further understand and agree to the following:

• I certify that the statements made in this application are true and correct to the best of my knowledge, and that falsification of any information contained herein may result in summary termination of my employment.
• An investigation may be done to obtain character information from employers, neighbors, friends, colleagues and associates, and others who may have knowledge of me.
• A satisfactory evaluation of my knowledge, skills, abilities, and overall suitability for employment, determined in part on the basis of any medical examination and drug screen test results and conducted by Caretech, Inc. in its sole and unlimited discretion, shall be a condition to employment. I shall take all tests required for the position I seek.
• I shall provide proof of citizenship or authority to work in the United States.
• My employment at Caretech, Inc. is at the will of Caretech, Inc. and myself and may be terminated, with or without cause, by Caretech, Inc. or myself at any time with no notice required.
• Caretech, Inc. may change the terms and conditions of my employment at any time without giving notice.
• No one but the President or a designated representative of Caretech, Inc. has the authority to enter into any contract for employment with me which contains terms that are contrary to any herein.
• If my employment ends, Caretech, Inc. may provide confidential information from my records to any prospective employer with no liability to itself or its staff.

Caretech, Inc. is an Equal Opportunity Employer and adheres to all anti-discriminatory laws, local, state, and federal.