Sworn Statement 宣誓聲明 I acknowledge and agree to the following. 本人特此確認及同意以下內容: 1. I confirm that I have not been found guilty of patient or resident abuse. 本人確認,本人未曾被判定對病人或住戶有虐待行為。 2. I confirm that I have not been convicted of any crime or violation, other than a traffic infraction. 本人確認,本人未曾被定罪或有違規行為,交通違規除外。 3. I understand that my temporary employment is contingent upon the successful completion of my background check. 本人明白,本人的臨時僱用狀態需以背景調查的成功完成為條件。 4. I understand that providing false or misleading information may result in the immediate termination of my temporary employment. 本人明瞭,提供虛假或誤導性信息可能導致本人的臨時聘用立即被終止。Background Check and Fingerprinting Consent 背景調查和指紋採集同意書 By signing below, I give consent for the background check and fingerprinting process to proceed. I understand that, upon providing my consent, Golden Touch will submit my information for the background check. Once a notification is received from the DOH system, I will be informed to schedule my fingerprint appointment. 背景調查及指紋採集同意書 通過在下方簽名,我同意進行背景調查和指紋採集程序。我了解,經我同意後,萬有護理公司將提交我的信息進行背景調查。一旦收到政府系統的通知,我將被通知安排指紋採集的預約。Name(Required) First Name (名) Last Name(姓) D.O.B 生日(Required) MM slash DD slash YYYY Aide Code 護理編號(Required)Address 地址(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Signature 簽名(Required)Date 日期(Required) MM slash DD slash YYYY