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。Name(Required) First Name (名) Last Name(姓) Aide Code 護理編號(Required)This field is hidden when viewing the formD.O.B 生日(Required) MM slash DD slash YYYY Signature 簽名(Required)Date 日期(Required) MM slash DD slash YYYY This field is hidden when viewing the formAddress 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