Employment Application

Please list three professional references.

May we contact your previous employer for a reference?

May we contact your previous employer for a reference?

May we contact your previous employer for a reference?

If other than honorable, explain:

Licenses/Certifications-Please include copies of certifications with this application.

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my immediate release.

A Fair Choice, Inc. is an Equal Opportunity Employer (EEO) and does not discriminate against race, color, national origin, age, sex, disability, political beliefs, and/or religion.

c Provide Employee with AFC Employee Handbook

c Conduct a General Orientiation

c Abuse, Neglect & Exploitation Form

c IRS Form W-4 AND USCIS Form I-9

c Infection Control Guidelines

c Criminal Records Affidavit & Release

c False Claims Act Acknowledgement

c DPS Computerized Criminal History Verification

c Permission to Obtain Driving Record

c Acknowledgement of Driving Status

c Reporting of Abuse & Neglect

c Introductions to staff and clients

c Review initial job assignments and training plans

c Review job description and performance expectations and standards

c Review job schedule and hours

c Review payroll timing, time cards, and policies & procedures.

1320 W. Pioneer Parkway, Arlington, TX 76013; Office: (817) 200-6110; Fax: (817) 200-7572

The clients whom you will be caring for have been diagnosed with an intellectual (mental) and or physical disability. Our goal is to assist our clients in reaching their fullest potential possible. Staff(s) are hired/contracted to provide training in activities of daily living. These areas include assisting and prompting in personal hygiene, social skills, meal preparation, money management, and overall improving and developing independent living skills. A Fair Choice, Inc. will only provide “World Class Service” to all of our clients by meeting each client’s unique needs.

The clients in your care may have behavioral problems that can range from name calling, spitting, hitting, elopement, etc. As the staff it is your responsibility to keep yourself and the client safe and un-harmed. De-escalating the situation, negotiating, and reasoning with the client may be necessary to maintain a safe environment. A Fair Choice, Inc. will provide additional Crisis Prevention Intervention training to assist with this area. Physical intervention will always be a last resort and will be used only as an intervention to prevent the clients form harming themselves and/or others.

Every client will need detailed assistance with personal hygiene- i.e. bathing, dressing, toileting, menstrual care, personal grooming, etc. Patience will be required of you to complete these tasks. Routines and repetition are key with the clients and there will be times where you will have to repeat yourself several times every day. Demonstrating complete patience, understanding, problem solving, honesty, and an overall positive “can do” attitude will aid in success with the clients.

As a member of the A Fair Choice, Inc. team you will be rewarded. Your contributions in bettering another person’s life are invaluable. This line of work will give you meaning and purpose. Every day, every shift there will always be someone who is depending on you and willing to provide unconditional love towards you. You will continually be surprised at the progress the clients will have with your hard work and dedication to providing excellence.

Now that you have a glimpse of what this line of work entails, please complete the following written examination. The objective of this examination is to measure your knowledge of how you would handle possible job occurrences. The examination consists of twelve (12) questions. All questions should be attempted. Select or write a brief response to each question.

Read the following description of situations you may encounter while working with clients in the group home or in the community. Select or write a brief response to the question asked.

1. The following is a copy of medication label. Look over this label and read it carefully then answer the following questions.

4567 N. Pharmacy Blvd. Dallas, Texas 75001

123 Old Dirt Road, Dallas, TX 75001

TAKE 1 TABLET IN THE EVENING HOLD IF BLOOD SUGAR LESS THAN 75

a.How many tablets are to be taken at once? b. What is the name of the medication? c.When is this medication to be taken?

2. You are supervising medication and you notice the instructions on the medication record do not match the instructions on the medication, what do you do?

3. One of your duties is to prepare a healthy meal. One client has no diet restrictions, one is diabetic, and another is on a low salt diet. Describe the items you would prepare as an evening meal?

4. You have prepared your nutritious meal, but one of the clients has just gotten paid and wants to buy pizza for the house. What would you do?

5. You are preparing dinner when a client becomes angry. She knocks over items in the kitchen, knocks items out of your hand, and spits on you. What would you do?

6. How long should an individual go without a bowel movement?

7. You are providing care for two clients; one client has frequent seizures and needs help safely getting in and out of the tub. While assisting the client, the other yells “I am leaving!!” You then hear the door open and shut. Circle the best response.

a.Make sure the client in the tub is safe and tell them not to get out of the tub, go quickly to look for the other client that left. b. Tell the client in the tub to bathe quickly and be careful getting out of the tub, while you look for the client that left. c.Get the client out of the tub and then look for the client that left.

8. While on an outing with client, you become thirsty. What do you do? a.Stop and buy you something to drink. b. Wait until you get to the group home for something to drink. c.Stop and buy everyone something to drink. d. Both A and B. e.Both B and C. f.Both A and C.

9. You are responsible for completing the evening route and you have the ONLY van. The van you are driving is a seven-passenger can and you have eight individuals that you need to pick-up. What would you do?

10. While on an outing to the mall, one of the clients sees an item that they want. The client has no money and begins to have a temper tantrum while in the mall. What would you do?

11.A client is scheduled for a medical procedure, and the RN has instructed that the client is to be on clear liquids for the next two days. What are the examples of food items that the client may eat?

12. Please write a sample of a daily progress note (Daily living activities that you completed/assisted the client with

to work during these hours each day:

Any absences must be pre-approved.

Time off during the Summer will be

limited and on a first request, first

Schedule requests should be made AT LEAST 3 weeks prior to time needed off.

Specified days requested off are not guaranteed to be granted. If the schedule permits, the time needed off will be granted.

Schedules will be made 2 - 4 weeks in advance. All schedules are made in two week blocks. If you need a day off that you are already scheduled for, then you must find an approved sub to cover your shift.

, have never been convicted of any of the following offenses under which would bar

1) 2)An offense under Section 20, Penal Code (kidnapping and false imprisonment) 3)An offense under Section 21.02, Penal Code (continuous sexual abuse of a young child or children) 4)An offense under Section 21.08, Penal Code (indecent exposure) 5)An offense under Section 21.11, Penal Code (indecency with a child) 6)An offense under Section 21.12, Penal Code (improper relationship between educator and student) 7)An offense under Section 21.15, Penal Code (improper photography or visual recording) 8)An offense under Section 22.011, Penal Code (sexual assault) 9)An offense under Section 22.02, Penal Code (aggravated assault) 10)An offense under Section 22.021, Penal Code (aggravated sexual assault) 11)An offense under Section 22.04, Penal Code (injury to a child, elderly individual or disabled individual) 12)An offense under Section 22.041, Penal Code (abandoning or endangering a child) 13)An offense under Section 22.05, Penal Code (deadly conduct) 14)An offense under Section 22.07, Penal Code (terroristic threat) 15)An offense under Section 22.08, Penal Code (aiding suicide) 16)An offense under Section 25.031, Penal Code (agreement to abduct from custody) 17)An offense under Section 25.08, Penal Code (sale or purchase of a child) 18)An offense under Section 28.02, Penal Code (arson) 19)An offense under Section 29.02, Penal Code (robbery) 20)An offense under Section 29.03, Penal Code (aggravated robbery) 21)An offense under Section 33.021, Penal Code (online solicitation of a minor) 22)An offense under Section 34.02, Penal Code (money laundering) 23)An offense under Section 35A.02, Penal Code (Medicaid fraud) 24)An offense under Section 36.06, Penal Code (obstruction or retaliation) 25)An offense under Section 37.12, Penal Code (false identification as peace officer) 26)An offense under Section, 42.01(a) (7), (8), or (9), Penal Code (disorderly conduct) 27)An offense under Section 42.09/42.092, Penal Code (cruelty to livestock animals or cruelty to non-livestock animals); or 28)Conviction under the laws of another state, federal law, or the Uniform Code of Military Justice for an offense containing the elements that are substantially similar to the elements of an offense listed.

An offense under Section 19, Penal Code (criminal homicide)

Neither have I been convicted of any of the following offenses which potentially may bar employment:

Assaultive Offenses (under Section 22.01) - Securing Execution of a Document by Deception (under Chapter 32.46) - Possession of Weapons - Felony Violation for the Possession or Distribution of a Controlled Substance - Disorderly Conduct (under Section 42.01) - Misapplication of Fiduciary Property or Property of a Financial Instrument (under Section 32.45)

- Burglary and Criminal Trespass (under Section 30.02) - Theft (under Chapter 31) - Public Indecency - Public Lewdness

I hereby allow A Fair Choice, Inc. to conduct a criminal record check in order to verify the above statement. Below is a space for me to inform A Fair Choice, Inc. of anything that will be on my record and to provide explanation:

The Texas Department of Aging & Disability Services maintains registries of individuals who have been found to have abused, neglected, or exploited a consumer, or misappropriated a consumer’s property. I have never been investigated by the Texas Department of Aging & Disability Services and found to have abused, neglected, or exploited a consumer, nor have I been found to have misappropriated a consumer’s property. A Fair Choice, Inc. is required by law to search the Employee Misconduct and Nurse Aides Registries before hiring an employee. A Fair Choice, Inc. is prohibited from employing a person who is listed in the registries as having abused, neglected, or exploited a consumer or misappropriated a consumer’s property.

, am not now, nor have I ever been recorded in the Employee Misconduct Registry (EMR), nor the Nurse Aides Registry (NAR) under Texas Health and Safety Code Section 253.007. I hereby allow A Fair Choice, Inc. to sear the EMR & NAR. I verify, also, that I have read and understand the company’s policy concerning client abuse. I further acknowledge and agree that my signature below will serve as my resignation if a criminal history check reveals any conviction for any of the above listed offenses which I have not revealed herein and/or if I am found to be listed in the EMR or NAR.

Print Employee/Contractor Name

The False Claims Act (FCA) provides, in pertinent part, that:

(a) Any person who (1) knowingly presents, or causes to be presented, to an office or employee of the United States Government or a member of the Armed Forces of the United States a false or fraudulent claims for payment or approval; (2) knowingly makes, uses, or causes to be made or used, a false record or statement to get a false or fraudulent claims paid or approved by the Government; (3) conspires to defraud the Government by getting a false or fraudulent claim paid or approved by the Government; or (7) knowingly makes, uses, or causes to be made or used, a false record or statement to conceal, avoid, or decrease an obligation to pay or transmit money or property to the Government, is liable to the United States Government for a civil penalty of not less than $5,000 and not more than $10,000, plus 3 times the amount of damages which the Government sustains because of the act of that person (b)For purposes of the section, the terms “knowing” and “knowingly” mean that a person, with respect to information, (1) as actual knowledge of the information; (2) acts in deliberate ignorance of the truth or falsity of the information or (3) acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required.

31 U.S.C. § 3729. While the False Claims Act imposes liability only when the claimant acts “knowingly,” it does not require that the person submitting the claim have actual knowledge that the claim is false. A person, who acts in reckless disregard or in deliberate ignorance of the truth or falsity of the information, also can be found liable under the Act. 31 U.S.C. § 3729(b

In sum, the False Claims Act imposes liability on any person who submits a claim to the federal government that he or she knows (or should know) is false. An example may be a physician who submits bill to Medicare for medical services he/she knows that he/she has not provided. The False Claims Act also imposes liability on an individual who may knowingly submit a files record in order to obtain payment from the government. An example of this may include a government contractor who submits records that he/she knows (or should know) are false and that indicate compliance with certain contractual or regulatory requirements. The third area of liability includes those instances which someone may obtain money from the federal government to which he/she may not be entitled, and then uses false statements or records in order to retain the money. An example of this so-called “reverse false claim” may include a hospital who obtains interim payments from Medicare throughout the year, and then knowingly files a false cost report at the end of the year in order to avoid making a refund to the Medicare program.

In addition to its substantive provisions, the FCA provides that private parties may bring an action on behalf of the United States. 31 U.S.C. § 3730(b The private parties, known as “qui tam relators,” may share in a percentage of the proceeds from a FCA action or settlement.

31 U.S.C. § 3730(d1) of the FCA provides, with some exceptions, that a qui tam relator, when the Government has intervened in the lawsuit, shall receive at least 15 percent but not more than 25 percent of the proceeds of the FCA action depending upon the extent to which the relator substantially contributed to the prosecution of the action. When the Government does not intervene, 31 U.S.C. § 3730(d2) provides that the relator shall receive an amount that the court decides is reasonable and shall be not less than 25 percent and not more than 30 percent.

The FCA provides protection to qui tam relators who are discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of their employment as a result of their furtherance of an action under the FCA 31 U.S.C. § 3730(h Remedies include reinstatement with comparable seniority as the qui tam relator would have had but for the discrimination, two times the amount of any payback, interest on any back pay, and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys’ fees.

I hereby acknowledge that I have been informed about federal and state fraud and false claims laws and the whistleblower protections available under those laws. I further understand that violation of such laws is strictly against the policy of A Fair Choice, Inc. and will result in immediate termination of employment or contract.

1320 W. Pioneer Parkway Arlington, TX 76013 Office: (817) 200-6110 Fax: (817) 200-7572

_, acknowledge that a Computerized Criminal

APPLICANT or EMPLOYEE NAME (Please Print)

History (CCH) verification check will be performed by accessing the Texas Department of Public Safety Secure Website and will be based on name and DOB identifiers that I supply.

Because name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history, the organization conducting the criminal history check for background screening is not allowed to discuss with me any criminal record information obtained using the name and DOB method. Therefore, the agency may request that I also have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search.

For the fingerprinting process I will be required to submit a full and complete set f my fingerprints for analysis through the Texas Department of Public Safety AFIS (Automated Fingerprint Identification System I have been made aware that in order to complete the fingerprint process, I must make an appointment with the L1 Enrollment Services, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $25.00 to the fingerprinting services company, L1 Enrollment Services.

Once this process is completed and the agency receives the data from the DPS, the information on my fingerprint criminal history record may be discussed with me.

(This copy must remain on file by this agency. Required for future DPS Audits)

Signature of Applicant or Employee

Please: Check and Initial ach Applicable Space

Agency Representative Name (Please print)

Signature of Agency Representative

1320 W. Pioneer Parkway Arlington, TX 76013 Office: (817) 200-6110 Fax: (817) 200-7572

My signature below indicates that I have searched the required state and federal databases for individuals and entities excluded from and type of reimbursement, direc tor indirect, from Medicaid, Medicare, the State Children’s Health Insurance Program and all federal healthcare programs.

Texas – https://oig.hhsc.state.tx.us/exclusions/search.aspx

Federal – http://www.oig.hhs.gov/fraud/exclusions.asp

The applicant named above is not listed in either database and is therefore eligible for hire if all other criteria for employment are met.

1320 W. Pioneer Parkway Arlington, TX 76013 Office: (817) 200-6110 Fax: (817) 200-7572

, understand that I am to immediately (at least within one hour) report any incident of abuse or neglect to my immediate supervisor and/or the on-call person.

I understand that I may be criminally liable for failure to report abuse. I further understand that the facility may not suspend, terminate, discipline or discriminate against me as a result of my good faith effort to report abuse or neglect of a client, consumer or resident.

I know I can notify the abuse hotline myself if I do not want to notify A Fair Choice, Inc. staff.

All allegations of abuse, neglect, or exploitation should be reported within 1 HOUR of knowing or suspecting that the act occurred.

Within 1(ONE) HOUR of witnessing the abuse neglect or exploitation. You may remain

anonymous. Within 1 hour of witnessing the violation.

It is the responsibility of any person who has knowledge of any real or suspected abuse, neglect, or exploitation to report it within the HOUR through the above telephone number. All reporting is confidential. Any persons employed by a contracting provider are required to cooperate fully with all aspects of any investigation conducted by DFPS.

Abuse: Any act or failure to act knowingly, recklessly, or intentionally, including incitement to

act, which results in physical, mental, or emotional harm to the consumer.

Verbal Abuse: Any use of verbal or other forms of communication to curse, criticize, degrade,

Neglect: Negligence on the part of any person which causes physical, mental, or emotional

Exploitation: Any Act requested of the consumer by another person for personal gain such as

lending money, sexual exploitation, or performing work for which he or she is not compensated appropriately.

DADS and OSHA policies and Texas & Federal laws mandate the use of UNIVERSAL PRECAUTIONS by Healthcare Workers.

As stated in the Texas Health and Safety Code Chapter 85, Human Immunodeficiency Virus Services Act 1991; “Universal Precautions” means procedures for disinfection and sterilization of Reusable Medical Devices. The appropriate use of infection control, including hand

washing, the use of protective barriers, and the use/disposal of needles and other sharp instruments as those procedures are defined by the Center for Disease Control of the United States Public Health Services.

Wash hands thoroughly both before and after consumer care, eating, assisting consumers with eating, after contact with any body fluids or wastes, upon arrival to work and before going home. Assure that liquid soap and paper towels are available at each sink. Immediately wash bites, scratches, cuts, or abrasions with soap and water. Wear appropriate gloves when in contact with blood, semen, vaginal secretions, weeping wounds, specimens, or other organic material such as urine and feces.

Used needles; without recapping in readily accessible sharps disposal boxes. Contaminated trash, waste matter, tissues, dressings, soiled disposable gloves, etc.- in tear proof sealed bags. Wipe up any spills or accidents involving body fluids with a disinfectant (such as and institutional disinfectant Spray surface, leave on for approximately 10 minutes and wipe down.

Any Health Care Worker with weeping wounds, bleeding lesions, or other potentially infectious conditions should refrain from performing or assisting in invasive procedures on consumers.

I acknowledge that I have received information on the guidelines for Universal Precautions. I am aware that I am expected to follow these precautions at all times. Because of my job duties and the environment in which I will be working, I am aware that even with preventive measures, exposure to particular communicable diseases is a possibility.

My signature below acknowledges that I have received, HIPPA Training and that I understand the following HIPPA related information, policy, and procedures:

HIPPA is the Health Insurance Portability and Accountability Act. The Department of Health and Human Services, Office of Civil Rights; enforces HIPPA regulations. Past, present, and future physical or mental health conditions of a consumer is protected health information (PHI PHI can be disclosed for issues related to the consumer’s treatment, payment of consumer services, and for operation the agency. A privacy notice is a document that describes how medical information about a consumer may be used and disclosed. Anyone who is unknown to you should be required to provide proof of who they are and why the need access to the consumer’s protected health information. When not in use, consumer records should be locked in a cabinet, cupboard, or closet. The consumers we support and their legal guardians may have access to the consumer’s served medical records. Records must be locked in the trunk of the car or a locked container when being transported in a vehicle. In a public location, it is best not to discuss PHI at all, but if needed to assist a colleague in providing services, you must ensure that no one overhears. Once a consumer has been discharged from a program, their medical records will be identified by his/her initials. Electronically transmitting a bill containing protected health information to Medical facilities for payment of services provided to the consumer must be in a HIPPA covered transaction. Access rights to computer data should be terminated immediately upon the employee’s departure from employment and the access is still applicable. Ensure keys are accessible to only those staff that needs access to this information to perform their job. Computers that contain protected health information should have the monitors turned so that someone walking by cannot read the information. Fax machines should be located in areas that are not readily accessible to the public. All faxes and outgoing emails should have a confidentially notice in accordance with HIPPA policy. HIPPA Fines for violating HIPPA regulations can add up to $25,000 per consumer, per rule violation, per year. Intending to use PHI under false pretenses or selling this information to a vendor can result in a fine of $250, 000 and or 10 years in prison.

As an employee of AFC, you have the right to be heard without fear of retaliation.

As specified in the Health and Safety Code 252.132.133, as a facility may not retaliate or discriminate against a staff member, volunteer, a resided, or a family member/guardian of a resident because the person:

Makes a complaint or files a grievance concerning the facility Reports a violation of law or regulation; or Initiates or cooperates in an investigation relating to the care, services, or conditions at the facility.

Como emplado, usted tiene el derecho de ser escuchaso sin temor a represalias

Como se especifica en el codigo de salubridad seguridad 252.132.133, una entidad no puede discriminar o tomar represalias contra un miembro del personal, un voluntairo, un residente, un familiar/tutor de un residente debido a que la persona:

Se queja o presenta un agravia con respect a la entidad Informa sobre una violacion de alguna ley o reglamento Incia o collaboration en una investigacion relacionada con el cuidado, los, servicios o las condiciones de la enti

1320 W. Pioneer Parkway Arlington, TX 76013 Office: (817) 200-6110 Fax: (817) 200-7572

I, the undersigned, recognize that any material concerning any and all clients of the facilities or any person making contact with the facilities is to remain in the strictest of confidence. No material concerning a particular client may be released to or discussed with anyone outside the facility staff without prior knowledge and written consent of the client or legal guardian (in the case of adjudicated clients

I understand the violation of client confidentiality while a member of this staff is grounds for immediate termination and that any violation of client information either while employed or following my termination from the facilities, could result A Fair Choice, Inc. pursuing any and all legal recourse available against me.

HCS/TxHmlProvider/ Family Support Services

1320 W. Pioneer Parkway Arlington, TX 76013 Phone (817) 200-6110 Fax (817) 200-7572

1.Being a good listener means: A.Judging what the speaker says B.Pay attention to what is being said and how it is being said C.Offering your opinion D.Making a rude comment

2.Describe reflective listening. A.Using a mirror to show the patient what they look when they are talking to you. B.A technique by which you can let the other person know that you heard what they said by repeating their words to them C.Knowing the right cliché to use D.Listening and interrupting the client

3.The term boundaries refers to: A.The property owned by the patient B.The limits that must exist in the relationships we develop with patients and their families C.The counties served by A Fair Choice, Inc. D.None of the above

4.Confidentiality means: A.You have enough confidence to do your job B.People have confidence in you and your work C.Any information you see or hear about the client, family, or friends is NEVER to be shared D.All of the above

5.While training your consumer to bathe, you have an opportunity to A.Talk about your personal life B.Visit with the consumer C.Observe for safety and skin conditions/breakdown D.All of the above

6.When documenting information, it is important to: A.Report and record exactly how you feel about the situation B.Report and record exactly what you see C.Report and record what the family feels is wrong D.All of the above

7.Good hand washing technique is important because: A.It prevents the spread of germs B.It is required by the health department C.It is good for the patient’s health and moral D.None of the above

8.When training a consumer it is best to: A.Use verbal prompts B.Do the task yourself C.Yell at the consumer D.None of the above

9.Mr. Smith’s diaper contains a very large amount of dark red urine. What should you do? A.Encourage him to drink more fluids B.Change him and wash your hands C.Call your nurse or supervisor as soon as you can D.None of the above

10.When changing Maria’s diaper, you noticed bruises and marks on her bottom. What should you do? A.Call Protective Services, Document, report it to your supervisor B.Call 911 C.Ask the family what happened D.None of the above

11.When training Bob to eat, you notice that he begins to choke on his food. What should you do? A.Call 911 B.Perform the Heimlich maneuver C.Tell him to slow down and chew his food properly D.None of the above

1320 W. Pioneer Parkway Arlington, TX 76013 Office: (817) 200-6110 Fax: (817) 200-7572

Address: City, State & Zip Phone:

Address: City, State & Zip Phone:

Address: City, State & Zip Phone:

1320 W. Pioneer Parkway Arlington, TX 76013 Office: (817) 200-6110 Fax: (817) 200-7572

I hereby allow A Fair Choice, Inc. to obtain a record to verify my driving history.

Please list all accidents or traffic tickets within the past three (3) years:

1320 W. Pioneer Parkway Arlington, TX 76013 Office: (817) 200-6110 Fax: (817) 200-7572

, understand that I cannot drive any vehicle belonging to A Fair Choice, Inc. or any vehicle used in transporting clients of A Fair Choice, Inc. until A Fair Choice, Inc. has received a positive report on my driving record. I also understand that violation of this policy will result in my immediate termination of employment.

Pending the result or due to the result of my driving record, I understand that:

to drive any vehicle belonging to A Fair Choice, Inc. or any vehicle used in transporting clients of A Fair Choice, Inc.

I also understand that vehicle use is restricted to authorized company use only.

Violation of these policies will result in my immediate termination of employment.

1320 W. Pioneer Parkway Arlington, TX 76013 Office: (817) 200-6110 Fax: (817) 200-7572

, do hereby acknowledge and agree that I may transport clients or employees of A Fair Choice, Inc. ONLY if all of the following are true and correct:

1 The vehicle I am using to transport is in good repair, has a current and valid state registration and inspection, is safe and legal to drive, and 2I have a current and valid driver’s license to drive in the state of Texas, and 3 I have current and valid auto insurance on the vehicle I am using to transport A Fair Choice, Inc. clients or employees.

Additionally, I hereby acknowledge and agree that in the event of any accident, I will immediately:

1 Contact 9-1-1 for police, fire or ambulance AND 2 Contact the CEO, Program Director and/or my immediate supervisor.

I understand and agree that I will contact the Program Director and/or my immediate supervisor in the event of any accident OR traffic violation/citation, whether work related or personal, in order to satisfy the terms of the company insurance coverage.

I further acknowledge that my signature below shall serve as immediate resignation should I fail to comply with any of the aforementioned criteria.

Employees may use company vehicles for job related activities only if they have a clear MVR, have a signed Acknowledgement of Driving Status form and are on the list of authorized drivers. Our company vehicles are covered by our company auto insurance policy with at least the state minimum requirements for physical damage and bodily injury.

Employees who use their personal vehicles for business purposes are not covered by company insurance. The employee’s personal auto insurance is the primary coverage and will be responsible for any damages or injuries incurred in the event of an accident.

Furthermore, no employee may borrow a vehicle from any other individual to perform company business. This includes other employees, family, clients and foster care providers - not anyone.

1320 W. Pioneer Parkway Arlington, TX 76013 Office: (817) 200-6110 Fax: (817) 200-7572

In case of emergency, please contact the following:

I hereby authorize A Fair Choice, Inc. to initiate automatic deposits to my account at the financial institution named below. I also authorize A Fair Choice, Inc. to make withdrawals from this account in the event that a credit entry is made in error.

Further, I agree not to hold A Fair Choice, Inc. responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account.

This agreement will remain in effect until A Fair Choice, Inc. receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to the Payroll Department.

Name of Financial Institution:

Authorized Signature (Primary):

Please attach a voided check or deposit slip and return this form to the Payroll Department.

I understand and agree with the policies and conditions set forth by A Fair Choice, Inc. in this Employee Handbook. Any violation of these policies constitutes grounds for disciplinary action, up to and including termination of employment.

Upon separation from A Fair Choice, Inc. I understand that I must return all company property (i.e., keys, badges, etc before receiving a final paycheck. I further understand that if any or all of the items are not returned, the value of such items will be deducted from my final paycheck.

I also understand and acknowledge that A Fair Choice, Inc. reserves the right to modify, revoke, or discontinue any and/or all policies and procedures at its discretion.