Do not leave any field blank. Please TYPE N/A if anything does not apply to you Your Application will be considered incomplete and will not be considered for review!

Two Professional References

Reference # 1

Reference # 2

Required Documentation

LEAGAL AND CONSENT

It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or separation from the CHARITY CARE GROUP THE FOUNDATION’S service if I have been CONTRACTED. Furthermore, I understand that just as I am free to resign anytime, the CHARITY CARE GROUP THE FOUNDATION reserves the right to terminate my CONTRACTING at any time, with or without cause and without prior notice. I understand that no representative of the CHARITY CARE GROUP THE FOUNDATION has the authority to make any assurances to the contrary.

I give the CHARITY CARE GROUP THE FOUNDATION the right to investigate all police, driving, and personal records and references, if JOB, VOLUNTEER OR CONTRACTING related. I hereby release from liability the CHARITY CARE GROUP THE FOUNDATION and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

CHARITY CARE GROUP THE FOUNDATION is an ORGANIZATION. CHARITY CARE GROUP THE FOUNDATION does not discriminate in CONTRACTING and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for CONTRACTING on a basis prohibited by local, state or federal law.

Any controversy of any kind arising between the parties under this agreement or otherwise (or any agent, officer, director or affiliate of any party), including but not limited to common law, statutory, tort or contract claims, will be submitted to mediation and failing settlement in mediation, to binding arbitration. Unless otherwise agreed a mediation and arbitration designated by staff professionals will govern any mediation and arbitration. The parties will select the mediator or arbitrator from the designated company panel of mediators and will notify the designated company, in writing, to initiate the selection process. The arbitration will be subject to and governed by the provisions of the Federal Arbitration Act. 9 U.S.C. Section 1-et seq. The parties hereto stipulate that this agreement involves matters affecting interstate commerce.

This application is current for 60 days. At the conclusion of this time if I have not heard from the CHARITY CAREGROUP THE FOUNDATION and still wish to be considered for CONTRACTING, A JOB OR VOLUNTEERING it will be necessary to fill out a new application.