ࡱ > D G A B C q` " bjbjqPqP 5 : : ]) N N N N / / / 8 .0 < j1 D Q 2 ; " ; ; ; = \ v= , = P P P P P P P $ 1S h U | 4P = = = = = 4P N N ; ; h 9Q HD HD HD = N 8 ; ; P HD = P HD HD : I , 2J ; 2 DPi / > I
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D A T E O F B I R T H * _ F O R M T E X T _ _ B I R T H P L A C E * : _ F O R M T E X T _ _ S O C I A L S E C U R I T Y # _ F O R M T E X T _ _ G R E E N C A R D # : _ F O R M T E X T _ _
A R E Y O U A U . S . C I T I Z E N ? _ F O R M T E X T _
D O Y O U D R I V E ? _ F O R M D R O P D O W N _ D R I V E R S L I C E N S E # _ F O R M T E X T _ S T A T E _ F O R M T E X T _ E X P I R A T I O N _ F O R M T E X T _
C A N Y O U T R A V E L ? _ F O R M D R O P D O W N _
C A N Y O U R E L O C A T E ? _ F O R M D R O P D O W N _
A R E Y O U M A R R I E D ? * _ F O R M D R O P D O W N _
D O Y O U H A V E C H I L D R E N ? * _ F O R M D R O P D O W N _ I F S O , H O W O L D A R E T H E Y ? * _ F O R M T E X T _
C A N Y O U L I V E I N ? _ F O R M D R O P D O W N _ C A N Y O U W O R K W E E K E N D S ? _ F O R M D R O P D O W N _
P A R T T I M E H O U R S A N D D A Y S ? _ F O R M T E X T _
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R E F E R E N C E S
S T A R T W I T H M O S T R E C E N T P O S I T I O N / E M P L O Y E R
S t a r t d a t e
_ F O R M T E X T _ N A M E : _ F O R M T E X T _ P H O N E # ( F O R M T E X T ) F O R M T E X T - F O R M T E X T
C E L L # ( F O R M T E X T ) F O R M T E X T - F O R M T E X T E n d d a t e
_ F O R M T E X T _ A D D R E S S : _ F O R M T E X T _
C I T Y / S T A T E : _ F O R M T E X T _ J o b T y p e
_ F O R M D R O P D O W N _ J o b T i t l e / d e s c r i b e j o b : _ F O R M T E X T _
W H A T A G E S W E R E T H E K I D S W H E N Y O U S T A R T E D ? _ F O R M T E X T _ S A L A R Y
$ _ F O R M T E X T _ W H Y D I D Y O U L E A V E ? _ F O R M T E X T _
S t a r t d a t e
_ F O R M T E X T _ N A M E : _ F O R M T E X T _ P H O N E # ( F O R M T E X T ) F O R M T E X T - F O R M T E X T
C E L L # ( F O R M T E X T ) F O R M T E X T - F O R M T E X T E n d d a t e
_ F O R M T E X T _ A D D R E S S : _ F O R M T E X T _
C I T Y / S T A T E : _ F O R M T E X T _ J o b T y p e
_ F O R M D R O P D O W N _ J o b T i t l e / d e s c r i b e j o b : _ F O R M T E X T _
W H A T A G E S W E R E T H E K I D S W H E N Y O U S T A R T E D ? _ F O R M T E X T _ S A L A R Y
$ _ F O R M T E X T _ W H Y D I D Y O U L E A V E ? _ F O R M T E X T _
S t a r t d a t e
_ F O R M T E X T _ N A M E : _ F O R M T E X T _ P H O N E # ( F O R M T E X T ) F O R M T E X T - F O R M T E X T
C E L L # ( F O R M T E X T ) F O R M T E X T - F O R M T E X T E n d d a t e
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C I T Y / S T A T E : _ F O R M T E X T _ J o b T y p e
_ F O R M D R O P D O W N _ J o b T i t l e / d e s c r i b e j o b : _ F O R M T E X T _
W H A T A G E S W E R E T H E K I D S W H E N Y O U S T A R T E D ? _ F O R M T E X T _ S A L A R Y
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T O D A Y S D A T E
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H I G H S C H O O L :
F O R M T E X T
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F O R M T E X T
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W h a t a r e y o u r b e l i e f s r e g a r d i n g d i s c i p l i n i n g t h e c h i l d r e n y o u a r e c a r i n g f o r ?
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I a u t h o r i z e R o s e s A g e n c y / T h e A g e n c y / D D L D o m e s t i c s / T r u e N a n n i e s / A m e r i c a n C h i l d C a r e a n d p r o s p e c t i v e e m p l o y e r s t o o b t a i n a n i n v e s t i g a t i v e r e p o r t c o n t a i n i n g i n f o r m a t i o n a b o u t m e . I n c l u d i n g i n f o r m a t i o n o b t a i n e d t h r o u g h p e r s o n a l i n t e r v i e w s w i t h m y n e i g h b o r s , f r i e n d s , a n d a c q u a i n t a n c e s . T h i s r e p o r t m a y i n c l u d e i n f o r m a t i o n a s t o m y c h a r a c t e r , g e n e r a l r e p u t a t i o n , c r i m i n a l h i s t o r y , m o t o r v e h i c l e r e c o r d , a n d w o r k m a n s c o m p e n s a t i o n h i s t o r y . F u r t h e r , I a u t h o r i z e a c c e s s t o i n f o r m a t i o n r e g a r d i n g m y r e l i a b i l i t y , e m p l o y m e n t h i s t o r y , e d u c a t i o n ( i n c l u d i n g s c h o o l t r a n s c r i p t s ) , a n d d o c t o r a n d h o s p i t a l r e c o r d s . I a u t h o r i z e R o s e s A g e n c y / T h e A g e n c y / D D L D o m e s t i c s / T r u e N a n n i e s / A m e r i c a n C h i l d C a r e t o a c c e s s m y c o n s u m e r c r e d i t r e p o r t . I u n d e r s t a n d t h a t a n y n e g a t i v e i n f o r m a t i o n o b t a i n e d i n t h e s e i n v e s t i g a t i o n s m a y a f f e c t , a s a l l o w e d b y l a w , m y e m p l o y m e n t e l i g i b i l i t y , b u t t h a t a l l i n f o r m a t i o n w i l l b e e v a l u a t e d i n l i g h t o f m y a g e a t t h e t i m e s o f a n i n c i d e n t , a n d m y m o d e o f l i v i n g s i n c e t h e i n c i d e n t o c c u r r e d . I u n d e r s t a n d t h a t c o m p l e t i o n a n d p r o c e s s i n g o f t h i s a p p l i c a t i o n d o e s n o t o b l i g a t e R o s e s A g e n c y / T h e A g e n c y / D D L D o m e s t i c s / T r u e N a n n i e s / A m e r i c a n C h i l d C a r e t o e i t h e r h i r e o r p l a c e m e i n a n y p o s i t i o n .
I f u r t h e r a u t h o r i z e R o s e s A g e n c y / T h e A g e n c y / D D L D o m e s t i c s / T r u e N a n n i e s / A m e r i c a n C h i l d C a r e t o d i s t r i b u t e , c o p y , t r a n s m i t a n d f a x , a s a l l o w e d b y l a w , t h e i n f o r m a t i o n a b o u t m e t o p o t e n t i a l e m p l o y e r s , a n d t o a c t a s m y a g e n t i n s e e k i n g p o t e n t i a l e m p l o y m e n t f o r m e .
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I u n d e r s t a n d t h a t u p o n p l a c e m e n t , m y e m p l o y e r a n d I a r e r e s p o n s i b l e t o t h e I R S f o r a l l t a x o b l i g a t i o n s a r i s i n g o u t o f m y e m p l o y m e n t a n d t h a t I a m n o t a n e m p l o y e e o f R o s e s A g e n c y / T h e A g e n c y / D D L D o m e s t i c s / T r u e N a n n i e s / A m e r i c a n C h i l d C a r e .
I a g r e e t o h o l d R o s e s A g e n c y / T h e A g e n c y / D D L D o m e s t i c s / T r u e N a n n i e s / A m e r i c a n C h i l d C a r e h a r m l e s s f r o m a n y c l a i m s a g a i n s t i t r e s u l t i n g f r o m m y c o n d u c t , a n d I a g r e e t o f u l l y i n d e m n i f y R o s e s A g e n c y / T h e A g e n c y / D D L D o m e s t i c s / T r u e N a n n i e s / A m e r i c a n C h i l d C a r e f o r a l l c l a i m s f o r d a m a g e s d i r e c t l y o r i n d i r e c t l y r e s u l t i n g b e c a u s e o f m y e r r o r s a n d / o r o m i s s i o n s . I f u r t h e r r e l e a s e R o s e s A g e n c y / T h e A g e n c y / D D L D o m e s t i c s / T r u e N a n n i e s / A m e r i c a n C h i l d C a r e f r o m a l l c l a i m s f o r p e r s o n a l i n j u r i e s a n d d a m a g e s a s a r e s u l t o f t h i s p l a c e m e n t , i n c l u d i n g c l a i m s c a u s e d b y t h e a l l e g e d n e g l i g e n c e o f R o s e s A g e n c y / T h e A g e n c y / D D L D o m e s t i c s / T r u e N a n n i e s / A m e r i c a n C h i l d C a r e .
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