Authorization and Acknowledgements
I affirm that the information I have provided in this application is true to the best of my knowledge, information, and belief, and I have not knowingly withheld any information requested. I understand that withholding or
misstating any information requested in this application is grounds for rejection of my application and that
providing false or misleading information in this application is grounds for discharge.
I authorize The Rose Residential Care Home to verify my references, record of employment, education record,
and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to
disclose any information related to my work record and my professional experiences with them, without giving
me prior notice of such disclosure. In addition, I release The Rose Residential Care Home, LLC, my former
employers, and all other persons and entities, from any and all claims, demands, or liabilities arising out of or in
any way related to such inquiry or disclosure.