Certified Signature and Information Release

I hereby certify that the statements contained in this application or other documents submitted and the statements made during any interview process are true and complete to the best of my knowledge, and I understand that material omissions from or false statements made in this application or other documents submitted or occurring during any interview process shall be grounds for denial of employment or discharge.

I also voluntarily consent and submit to, and authorize Avalon through a physician chosen by it, to conduct a post-employment offer and future physical and medical examinations including drug and alcohol screening tests and that failure to pass such test(s)in whole or in part will be grounds for denial of employment or termination if employed at the time.

I understand that state law, AM Sub. S.B. 160, requires candidates who receive final consideration for certain positions in nursing homes, residential care facilities, homes for the aging, skilled nursing facilities and similar agencies to undergo a criminal record check and that individuals who have been convicted or pleaded guilty to prohibited offenses specified in the law, AM Sub. S.B. 160, may be disqualified for employment in covered agencies. Should I receive final consideration for employment, I consent and voluntarily submit to providing fingerprint impressions, a valid “certificate of no record” and other information which may be required to determine my eligibility for employment under AM Sub. S.B. 160.

I understand and agree that nothing stated in this employment application, in any other document, or in any interview is intended to create an employment contract between Avalon and myself for either employment or for providing any benefit. Likewise, no such contracts are intended to be created from the mere granting of an interview. No promises or guarantees regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon Avalon unless made in writing by the President/CEO and then only for the time specified or, is none is specified, for one week.

I understand and agree that if I am hired, my employment is for no definite period of time. I further understand and agree that, regardless of the date of the payment of wages, salary or benefits, my employment, including wages, salary or benefits may be terminated with or without cause and with or without notice at any time by Avalon. In addition, I understand that I likewise may terminate my employment with or without cause and with or without notice at any time.