Dear Applicant: Thank you for your interest in Liberty Home Care. Our agency ensures the highest quality of home care services for hospice patients and other individuals suffering from chronic illness. The company specializes in providing DME and oxygen to hospice and home-bound patients throughout Western New York. These vital home health services are provided quickly by internally trained staff. Liberty Home Care employees are an integral part of our mission. In order to be considered for an interview with Liberty Home Care you must complete all of the requirements listed below. New Applicant Requirements:

A. Completed Application and Resume with cover letter

B. Letter of Intent – Provide a letter detailing why you think you are the best candidate for the position, why you want to work for Liberty Home Care and what special qualities make you the best choice.

C. References – Two employment references and one personal reference are

required. The forms are included in this packet or you can submit three written letters of reference.

D. Consent form for Criminal Background Check – Also included in the packet is

consent for a criminal background check and a driver’s license check.

E. A copy of your Professional License or Certificate if applicable Once our interview team reviews all of the above information, you will be contacted. If you have any questions, please feel free to contact me at (716) 439-4417. Sincerely,

Sally Weber Human Resources Coordinator

Liberty Home Care APPLICATION FOR EMPLOYMENT

PERSONAL INFORMATION DATE:______________________ Name SS#__________________________ Last First Middle Present Address_________________________________________________________________________ Street City State Zip Permanent Address______________________________________________________________________ Street City State Zip Phone No. Are you 18 years or older Yes □ No □______________ E-mail Address:________________________________________________________________ Are you either a U.S. Citizen or an alien authorized to work in the United States? Yes □ No □___ Have you ever been convicted of a crime?___________________________________________________ If so explain:__________________________________________________________________________

EMPLOYMENT DESIRED DATE YOU SALARY POSITION CAN START DESIRED_____ IF SO MAY WE INQUIRE ARE YOU EMPLOYED NOW?______________________________________OF YOUR PRESENT EMPLOYER?_____________ EVER APPLIED TO THIS COMPANY BEFORE?_______________________WHERE?_____________________WHEN?_______ REFERRED BY______________________________________________________________________________________________ EDUCATION NAME & LOCATION OF SCHOOL # OF YEARS

ATTENDED DID YOU GRADUATE?

SUBJECTS STUDIED

GRAMMAR SCHOOL

HIGH SCHOOL

COLLEGE

TRADE, BUSINESS OR CORRESPONDENCE SCHOOL

GENERAL SUBJECTS OF SPECIAL STUDY OR RESEARCH WORK _______________________________________________ ___________________________________________________________________________________________________________ SPECIAL SKILLS:____________________________________________________________________________________________ ACTIVITIES: (CIVIC, ATHLETIC, ETC)_________________________________________________________________________ EXCLUDE ORGANIZATIONS, THE NAME OF WHICH INDICATES THE RACE, CREED, SEX, AGE, MARITAL STATUS, COLOR OR NATION OR ORIGIN OF ITS MEMBERS ______________________________________________________________________________________________________________________________________ U.S. MILITARY PRESENT MEMBERSHIP IN NAVAL SERVICE_________________________________________RANK_____________NATIONAL GUARD OR RESERVE The Age Discrimination in Employment Act of 1987 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.

(CONTINUED)

EMPLOYMENT HISTORY: LIST EMPLOYERS FROM MOST RECENT TO PAST EMPLOYER ADDRESS/PHONE NUMBER DATES

TO/FROM SALARY DUTIES/JOB TITLE

REASON FOR LEAVING:

EMPLOYER ADDRESS/PHONE NUMBER DATES TO/FROM

SALARY DUTIES/JOB TITLE

REASON FOR LEAVING:

EMPLOYER ADDRESS/PHONE NUMBER DATES TO/FROM

SALARY DUTIES/JOB TITLE

REASON FOR LEAVING:

EMPLOYER ADDRESS/PHONE NUMBER DATES TO/FROM

SALARY DUTIES/JOB TITLE

REASON FOR LEAVING:

REFERENCES: GIVE THE NAMES OF THREE PERSONS NOT RELATED TO YOU, WHOM YOU HAVE KNOWN AT LEAST ONE YEAR.

NAME ADDRESS BUSINESS YEARS ACQUAINTED

IN CASE OF EMERGENCY NOTIFY:_______________________________________________________________________________ NAME ADDRESS PHONE NO. I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT IF EMPLOYED, FALSIFIED STATEMENTS ON THIS APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND THE REFERENCES LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, AND RELEASE ALL PARTIES FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM FURNISHING SAME TO YOU. I UNDERSTAND AND AGREE THAT, IF HIRED, MY EMPLOYMENT IS FOR NO DEFINITE PERIOD AND MAY REGARDLESS OF THE DATE OF PAYMENT OF MY WAGES AND SALARY, BE TERMINATED AT ANY TIME WITHOUT PRIOR NOTICE AND WITHOUT CAUSE. DATE SIGNATURE The following information is requested by the Federal Government in order to monitor compliance with Federal laws prohibiting discrimination against applicants seeking to participate in this program. You are not required to furnish this information, but are encouraged to do so. This information will not be used in evaluating your application or to discriminate against you in any way. However, if you choose not to furnish it, we are required to note the gender, race/national origin of the individual applicants on the basis of visual observation or surname. Gender: Male_____ Female_____ Ethnicity: Hispanic or Latino_____ Not Hispanic or Latino_____ Race: (Mark one or more) White_____ Black of African American_____ American Indian/Alaskan native_____ Asian_____ Native Hawaiian or Other Pacific Islander_____

THE HOSPICE AND PALLIATIVE CARE GROUP, INC. NIAGARA HOSPICE, INC.

LIBERTY HOME CARE NIAGARA HOSPICE ALLIANCE, INC.

HR 5.0c EMPLOYMENT REFERENCE REQUEST

To: (Print Name and Address of Former Employer below) _______________________________________________________________ _______________________________________________________________ ______________________________________________Phone # _________________ I have applied for employment with Liberty Home Care and hereby authorize you to furnish the information requested below concerning my prior employment with your organization. In signing this authorization, I release your organization, its employees and/or its agents from any liability that may result now or later because of complying with this request. Employee’s Signature: ________________________________ Date: _______________ TO BE COMPLETED BY EMPLOYEE: ________________________________________________________________________ (Name: Last, First, Middle Initial) (Social Security Number) Employment Dates: From: __________________ to: ____________________ Last Position ________________________ Reason for leaving ____________________ TO BE COMPLETED BY EMPLOYER: Are employment dates correct? Yes No If no, what are correct dates? From _________ to:_______ Is the position title correct? Yes No If no, what is the correct title? _______________________ Is reason for leaving correct? Yes No If no, what is correct reason? _______________________ Is applicant eligible for rehire? Yes No If no, why? _____________________________________

OVERALL ASSESSMENT: Attendance Good Satisfactory Poor Punctuality Good Satisfactory Poor Performance Good Satisfactory Poor Completed by:___________________________ Title:________________ Date:______ Please return Employee Reference form in envelope provided.

THE HOSPICE AND PALLIATIVE CARE GROUP, INC. NIAGARA HOSPICE, INC.

LIBERTY HOME CARE NIAGARA HOSPICE ALLIANCE, INC.

HR 5.0c EMPLOYMENT REFERENCE REQUEST

To: (Print Name and Address of Former Employer below) _______________________________________________________________ _______________________________________________________________ ______________________________________________Phone # _________________ I have applied for employment with Liberty Home Care and hereby authorize you to furnish the information requested below concerning my prior employment with your organization. In signing this authorization, I release your organization, its employees and/or its agents from any liability that may result now or later because of complying with this request. Employee’s Signature: ________________________________ Date: _______________ TO BE COMPLETED BY EMPLOYEE: ________________________________________________________________________ (Name: Last, First, Middle Initial) (Social Security Number) Employment Dates: From: __________________ to: ____________________ Last Position ________________________ Reason for leaving ____________________ TO BE COMPLETED BY EMPLOYER: Are employment dates correct? Yes No If no, what are correct dates? From _________ to:_______ Is the position title correct? Yes No If no, what is the correct title? _______________________ Is reason for leaving correct? Yes No If no, what is correct reason? _______________________ Is applicant eligible for rehire? Yes No If no, why? _____________________________________

OVERALL ASSESSMENT: Attendance Good Satisfactory Poor Punctuality Good Satisfactory Poor Performance Good Satisfactory Poor Completed by:___________________________ Title:________________ Date:______ Please return Employee Reference form in envelope provided.

THE HOSPICE AND PALLIATIVE CARE GROUP, INC. NIAGARA HOSPICE, INC.

LIBERTY HOME CARE NIAGARA HOSPICE ALLIANCE, INC.

HR 5.0c PERSONAL REFERENCE REQUEST

To: (Print Name and Address of Reference below) ______________________________________________________________ _______________________________________________________________ ___________________________________________ Phone #__________________ I have applied for employment with Liberty Home Care and hereby authorize you to furnish the information requested below. I would be most grateful if you could assist us by completing this form and returning it to me in the envelope provided. TO BE COMPLETED BY EMPLOYEE: Employee’s Signature: ________________________________ Date: _______________ ________________________________________________________________________ (Print Name) TO BE COMPLETED BY PERSONAL REFERENCE: How long and in what capacity have you known this candidate? ______________________________________________________________________________________ Would you feel comfortable with this person taking care of a family member? ______________________________________________________________________________________ OVERALL ASSESSMENT: Reliability Good Satisfactory Poor Honesty Good Satisfactory Poor Trustworthy Good Satisfactory Poor Completed by:___________________________ Date:____________ Please return in the envelope provided.

If you do not have a resume please fill out this form. If you need more room please attach a separate sheet of paper.

RESUME NAME: ________________________________________________________________ ADDRESS: _____________________________________________________________ CITY: ____________________________ STATE: _______________ ZIP: ________ PHONE:_____________________ EMAIL ADDRESS: _________________________ PLEASE COMPLETE IN FULL THE INFORMATION BELOW. (If you require more space for the information requested below please complete on the back of this form.) EDUCATION: 1. _______________________________________________________________

2. _______________________________________________________________

3. _______________________________________________________________ WORK EXPERIENCE: 1. ________________________________________________________________ 2. ________________________________________________________________ 3. _______________________________________________________________ SPECIAL SKILLS 1. _______________________________________________________________ 2. ________________________________________________________________ 3. ________________________________________________________________