Employment Application Form

PART A: PERSONAL INFORMATION

AVAILABLE HOURS (in HH:MM format)

PART B: EDUCATION AND TRAINING

PART C: PRESENT AND PAST WORK HISTORY

WORK HISTORY

PART D: SUPPORTING STATEMENT

Please indicate all relevant experience, skills and work history that relate to the job description of which you have applied. Please print clearly. All illegible entries will not be considered.

PART E: MEDICAL HISTORY

PART F: REFERENCES

Please list three-character references of which we may contact

PART G: DECLARATION

hereby certify that all information included in the above application is true and valid to the best of my knowledge. I also understand that misrepresentation or falsification of the information provided above will result in my immediate disqualification from the selection process and dismissal from any position appointed to by the Agency after discovery.

CONFIDENTIAL AGREEMENT READ CAREFULLY AND SIGN BELOW IF YOU AGREE TO THESE TERMS OF EMPLOYMENT

I agree that except at the request and for the benefit of First choice health services inc. I will not disclose to anyone or use for my own purposes any of confidential or proprietary information, either during or after my employment. I understand and agree that First choice health services inc bidding, costs, pricing and marketing information and techniques, customer names and information, and employee name and information are confidential and proprietary to First choice health services inc.

I certify that this application contains no willful misrepresentation or falsifications and that this information given by me is true and complete to the best of my knowledge and belief. I authorized First choice health services inc to contact all sources to verify the information on this application. I understand that any falsification, misrepresentation or fraudulent information provided by me in connection with my application for employment is sufficient grounds for withdrawal of an employment offer or immediate discharge.

I understand that this application is not a contract of employment.

I authorize and request my former employers, references, and educational institutions which have information about me, to give First choice health services inc any and all information and opinions about me in their possession and which may lawfully be disclosed. I hereby waive written notice of such release of information and opinions, and release such former employers, references, and educational institutions from any liability or claim relating to such release of information and opinions. I also authorized and request federal, state, and local governmental agencies to release to First choice health services inc any information requested, concerning any criminal convictions on my record. A photocopy of this signed authorization and waiver shall be valid as an original.

CONFLICT OF INTEREST

I acknowledge that I have read the company policy statement concerning conflict of interest and I hereby declare that neither I, nor any other business to which I may be associated, nor, to the best of my knowledge, any member of my immediate family has any conflict between our personal affairs or interests and the proper performance of my responsibilities for the company that would constitute a violation of that company policy. Furthermore, I declare that during my employment, I shall continue to maintain my affairs in accordance with the requirements of said policy.

RELEASE OF INFORMATION

I hereby authorize all prior employers, schools, credit bureaus, Social security Administration. Law enforcement agencies and investigative agencies to give First choice health services inc all information concerning my previous employment and any pertinent information they may have personal or otherwise, concerning my qualifications for the position applied for. I release to First choice health services inc and all its employees form all liability for any damage that may result from furnishing information to First choice health services inc. I also release First choice health services inc and all its employees from all liability for any damage that may result from reliance on the information furnished. I understand that if a consumer investigative report is requested, I have the right under the Fair Credit Reporting Act to request in writing, within a reasonable time, a complete and accurate disclosure of the nature and scope of the investigation. This written request should be addressed to the location where this application is filed.