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Non-Misconduct
Non-Misconduct
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Name
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Last
Phone
Email
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Certify that this is true to the best of your ability:
*
☑️ I have never been shown by credible evidence (e.g. a court or jury, a department investigation, or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of intentional or gross negligent misconduct as evidence by an oral or written statement to this effect obtained at the time of application.
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Applicant’s Signature
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Date / Time
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Date
Time
Electronic Signature from Agency
signed Electronically by An Extra Hand Home Care
Linda Cooks / Owner
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