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APPLICATION FORM WAIVER

In exchange for the consideration of my job application by Mayfair Village Retirement Center (hereinafter called "the Company"), I agree that:

Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of Mayfair Village Retirement Center, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the Chairman of the Board. Both the undersigned and Mayfair Village Retirement Center may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise its benefits, policies and procedures and such changes may include reduction in benefits.

I understand that any offer of employment from Mayfair Village Retirement Center is contingent upon my successful completion of the Company's total preemployment screening process, including the Company's receiving references that it considers satisfactory, and my satisfactory completion of any post-job offer preemployment physical examination that the Company may require.

I hereby authorize the Company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize my former employers to disclose to the Company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Company, my former employers and all other persons, corporations, partnerships and associations from any and all claims demands or liabilities arising out of or in any way related to such investigation or disclosure.

I certify that I have not been excluded from any local, State or Federal Health Program and that no basis for any such exclusion exists. I further certify that I have not been the subject of any investigation or adverse action as defined under the Health Care Fraud and Abuse Data Collection Program. I agree to immediately notify the Company if I become subject to an inquiry or investigation by any government agency for health care fraud or abuse.

I certify that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. I also understand that my employment may be dependent upon my passing a physical examination, an approved driver's license check if applicable, and supplying legal proof of my identity and eligibility for employment.

I further understand that my employment with the Company shall be probationary for a period of sixty (60) days, and further that at any time during the probationary period or thereafter, my employment relationship with the Company is terminable at will for any reason by either party.

I UNDERSTAND THAT AS A CONDITION OF EMPLOYMENT WITH MAYFAIR VILLAGE RETIREMENT CENTER INCLUSIVE OF ASSISTED LIVING (KRS 216.793) A CRIMINAL BACKGROUND CHECK IS REQUIRED.

Employment Application