Please read the following statements carefully before you sign your name.

I, , hereby authorize and give consent for Sirrah Care Professionals, LLC and/or its agents to make an independent investigation of my background, addresses, social security number verification, sex offender registry checks, criminal/civil records, federal record, and child abuse clearance when applicable, including those maintained by both public and private organizations and all public records for purpose of confirming the information contained on my application and/or obtaining other information which may be material to qualify for client services.

I release any and all claims of liability, Sirrah Care Professionals, LLC and/or its agents and any person or entity, which provides information obtained from any and all of above referenced sources used.

I do hereby authorize Sirrah Care Professionals and/or its agents and any person or entity to disclose orally, electronically, and in writing the results of this background investigation. I have been given a stand-alone,consumer notification that a report will be requested and used for purposes of evaluating client services.

This authorization is executed with full knowledge and understanding that Sirrah Care Professionals, LLC will take measures to protect the aforementioned information against unauthorized disclosure to any parties not having a legitimate need for it.

The following information provided by me, is true and correct, to the best of my knowledge. A copy of this authorization shall be as effective and valid as the original.

(Please print legibly):

Employment with Sirrah Care Professionals, LLC are contingent upon favorable and acceptable background information.