(Proof of U.S. Citizenship or authorization to work in this country will be required upon employment)

Include the following for past employment: Start and End Dates. Employer Name & Address. Supervisor Name & Phone Number. Job Duties. Salary. Reason for Leaving

I understand that employment with Acute Home Healthcare is at will, and that either Acute Home Healthcare or I may terminate this employment at any time, for any reason, with or without prior notice and with or without cause.

I further understand that neither this application nor any other written or oral communication I may receive from Acute Home Healthcare constitutes a contract of employment and Acute Home Healthcare reserves the right at any time, to establish, modify, rescind or supplement any or all of its policies and benefits.

I authorize Acute Home Healthcare to contact any or all of my former employers listed herein and to inquire about my employment there. I release Acute Home Healthcare and any employer who is contacted from any liability arising out of such inquiry or the response to such inquiry.

I certify that the statement contained herein is true to the best of my knowledge and belief. I understand that any false or misleading statement made on this application or during the course of any employment interview, may result in a refusal of employment or, if employed, discipline up to and including immediate discharge.

I also understand that a Criminal History Record Check (Background Screening) may be performed in accordance with AHCA Regulations to determine employment eligibility.

If you hire me, I agree that while I am employed by Acute Home Healthcare, I shall not: (i) engage in any business that is competitive with any aspect of the business that is being conducted by Acute Home Healthcare; (ii) provide services to any client of Acute Home Healthcare that is not arranged for or contracted through Acute Home Healthcare; and (iii) provide any services that are provided by Acute Home Healthcare at any location where Acute Home Healthcare provides services that is not arranged for or contracted through Acute Home Healthcare.

I also agree that for a period of one (1) year after the expiration, termination or cancellation of this Agreement I shall not engage in any conduct described in subsections (ii) and (iii) of the foregoing sentence. Breach of this provision will cause irreparable damage to Acute Home Healthcare, Inc. and that, in addition to the other remedies available at law, an injunction or other equitable remedy may be issued to enforce this provision. In addition, in the event of a breach of this provision, I also agree and warrant to pay Acute Home Healthcare, Inc. an amount of $5,000.00 (Five thousand dollars).

AFFADAVIT

I have applied for a position with Acute Home Healthcare. All the information I have submitted is true to the best of my knowledge. All certificates are valid (or copies of valid originals) and all background information is correct. I authorize Acute Home Healthcare to obtain any information regarding and pertaining to my employment and health status. I understand that this may include contacting the following to obtain information to verify signatures, dates, forms and data:

• Medical providers (M.D. lab, etc.) • Previous employers • Schools and training programs • Personal and professional references • Federal Bureau of Investigations (FBI) • The State of Florida AHCA Criminal History background check

I further release Acute Home Healthcare, of any liability that may occur as a result of my personal negligence or as a result of any information that I wrongfully or fraudulently submitted to Acute Home Healthcare, or in the course of applying for a position during my association with them. I understand that any information fraudulently submitted will result in the immediate termination.

As a job applicant/employee of Acute Home Healthcare I hereby attest to the fact that I have received no special inducements, remuneration, or promises thereof to work for this agency. I understand that I will receive a salary commensurate and also in the line with what other benefits that I may be eligible for will be in Acute Home Healthcare accordance with policies established by Acute Home Healthcare.

Hiring of personnel, salaries, and benefits are awarded without regard to race, religion, disability, marital status, or sexual orientation. Acute Home Healthcare is an equal opportunity employer. I have read the preceding statements and I understand and agree with its contents.