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ATTESTATION OF GOOD MORAL CHARACTER

To be signed by applicants who have accepted a conditional offer of employment and will begin work on a
provisional basis after preliminary background check is , and pending the outcome of State or Federal
fingerprint background results. A copy of this signed attestation must be kept in the conditional hire’s personnel
file.

Name of Provisional Hire (print name):

Has accepted Provisional Employment with (location name):

I hereby attest I am of good moral character and I have not been convicted or found guilty of, or entered a plea of nolo contendere or guilty to, any misdemeanor or felony offense.

I hereby attest I am not disqualified from participation in Medicaid or Medicare programs and have not been sanctioned by any federal or state agency.

I hereby acknowledge my license/certification is in good standing with no pending or prior investigations.

Disclosures (if none state “none”):

This person is personally known to me or produced the following identification, Drivers License, on this October 2, 2023

Witness (type or print name): Charles Williams Title: Administrator

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Timestamp

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February 16, 2023 10:33 am EDT

Good Moral Attestation Uploaded by Assist Medical Staffing - staff@assistms.com IP 104.128.161.230

February 16, 2023 10:35 am EDT

Document owner richard@assistms.com has handed over this document to staff@assistms.com 2023-02-16 10:35:38 - 104.128.161.230