I do hereby authorize A&B Homecare and its representatives to conduct my reference check with all and any of the previous employers listed on my completed employment application form, submitted resume and on completed Personal Reference Check form. I hereby authorize and release A&B Homecare and its representatives conducting my reference checks and persons/organizations providing past employment information and references on my behalf from any liabilities whatsoever which may occur as a result of the said employment records, recommendations or any other communications pursuant of this authorization. Furthermore, I understand that this information will be placed in my personnel file as part of my employment record. I swear that all statements in this application are true and correct. I understand that false information may be cause for dismissal.

I have never been: 1.Convicted of any crime against children or other person: Aggravated murder; first or second degree murder; first or second degree kidnapping; first, second, orthirddegreeassault; first, second, or third degree assault of a child; first, second, or third degree rape; first, second, or third degree rape of a child; first or second degree robbery; first degree arson; first degree burglary; first or second degree man slaughter; first or second degree extortion; indecentliberties; incest; vehicular homicide; first degree promoting prostitution; communication with a minor; unlawful imprisonment; simpleassault; · sexual exploitation of minors; first or second degree criminal mistreatment; endangerment with a controlled substance; child abuse or neglect as defined in RCW 26.44.020; first or second degree custodial interference; first or second degree custodial sexual misconduct; malicious harassment; first, second, or third degree child molestation; first or second degree sexual mis conduct with a minor; patronizing a juvenile prostitute; child abandonment; promoting pornography; selling or distributing erotic material to a minor; custodial assault; violation of child abuse restraining order; child buying or selling; prostitution; felony indecent exposure; criminal abandonment; or any of these crimes as they may be renamed in the future. 2. Convicted of crimes relating to financial exploitation if the victim was a vulnerable adult: a conviction forfirst-, second-, or third-degree extortion; first, second or third degree theft; first or second degree robbery; forgery; or any of these crimes as they may be renamed in the future. 3. Convicted of crimes related to drugs: relating to drugs" means a conviction of a crime to manufacture, delivery, or possession with intent to manufacture or deliver a controlled substance. 4. Found in any dependency action under RCW 13.34.040 to have sexually assaulted or exploited any minor or to have physically abused any minor. 5. Found by a court in a domestic relation proceeding under Title 26 RCW to have sexually abused or exploited any minor or to have physically abused any minor.6.Found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or physically abused or exploited any minor or develop mentally disabled person or to have abused or financially exploited any vulnerable adult. 7. Found by a court in a protection proceeding under chapter 74.34 RCW to have abused or financially exploited a vulnerable adult. I swear that all statements in this application are true and correct. I understand that false information may because for dismissal.