Employment 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 release.

In exchange for the consideration of my job application by Specialized Health Care Services, LLC (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 SUPPORT Inc, Incorporated, 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 Executiveof the Company. Both the undersigned and Specialized Health Care Services, LLC 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 their benefits, policies and procedures and such changes may include reduction in benefits. I authorize investigation of all statements contained in this application, which may include a criminal background check, driver's license check, and Nurse Aide I and Health Care Personnel Registry check. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability as a result of such contact. Ialso understand that (1) the Company has a drug and alcohol policy that provides for preemployment testing as well as testing after employment; (2) consent to and compliance with such policy is a condition of my employment; and (3) continued employment is based on the successful passing of testing under such policy. I further understand that continued employment may be based on the successful passing of job-related physical examinations and a tuberculosis test. I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company, will provide me with additional information concerning the nature and scope of any such report requested by it, as required by the Fair Credit Reporting Act.

I further understand that my employment with the Company shall be probationary for a period of six months, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party. This Company is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, sexual orientation, national origin, citizenship, age or disability. We assure you that your opportunity for employment with this Company depends solely on your qualifications.

Thank you for completing this application form and for your interest in our Company.

Acknowledgment of Confidentiality

(Individual Information, Human Rights, HIPAA Compliance & Notice of Privacy Practice) In connection with my activities as a care provider or household family member, I agree to hold all information I may have access to about persons served or former persons served confidential and will not divulge any information to unauthorized persons. I understand that I am to use appropriate safeguards with respect to any health information in my possession to prevent the unauthorized use or disclosure of such protected health information. I agree to only use and disclose the health information in my possession as required by law or for the purpose for which it was disclosed to me. If I become aware of any instances in which the confidentiality of the health information has been breached, I agree to immediately notify Specialized Health Care Services, LLC and further agree that I will fully cooperate and provide any and all information requested. I understand that the divulging of confidential and / or protected health information to unauthorized persons will make me subject to either civil action for the collection of monetary damages and/or suspension or dismissal.

I understand that the restrictions and conditions noted above apply to any confidential or protected health information created, received, maintained, or transmitted in connection with my activities as a care provider or household member.

Each care provider or adult household member through Specialized Health Care Services, LLC by signing this notice is agreeing that they have received training on the Policy and Procedure on Confidentiality of Individual information, Human Rights, HIPAA compliance and the Notice of Privacy Practice. By signing this form, I agree to adhere to individual and human rights as indicated by state and local laws as well as the restrictions and conditions noted above.

I do fully acknowledge that I am in good physical health and can perform all duties as set forth in my job description. If at any time my health status changes, I will inform SHCS.

I understand that Specialized Health Care Services may now, or at any time while employed, verify information within the application, resume or contract for employment. The verifications and/or checks may include but not limited to: driving record, workers compensation records, credit bureau files, employment references, personal references, any educational and licensing institution and to receive any criminal record information pertaining to me which may be in the files of any Federal, State or Local criminal justice agency in any State. These reports may include information as to my general reputation, character, personal characteristics, or mode of living. A photocopy or telephonic facsimile (Fax) of this Disclosure and Consent authorization for Release of Information shall be valid as the original. The results of this verification process will be used to determine employment eligibility. All results will be kept CONFIDENTIAL. The information obtained will not be provided to any parties other than to the designated Specialized Health Care Services LLC personnel. I have carefully read and understand this disclosure and consent form and by my signature consent to the release of consumer or investigative consumer reports, as defined above in conjunction with my application for employment. I further understand this consent will apply during the course of my employment, should I obtain such employment, and that such consent will remain effect until revoked in a written document signed by me. In the event that I wish to refuse or revoke my consent at any time, I understand that I may do so. I further understand that any and all information contained in my job application, or otherwise disclosed to this company by me may be utilized for the purpose of obtaining the consumer reports or investigative consumer reports requested by Specialized Health Care Services LLC and confirm that all such information is true and correct. I further understand that I have the right to request, in writing, the nature and scope of any investigative consumer report. I, the undersigned applicant, do hereby certify that the information provided by me for the purpose of employment is true and complete to the best of my knowledge. I understand that if I am employed, any false statements will be considered as a cause for possible dismissal. I authorize Hirease, Inc. and any of its Agents, to disclose orally and in writing the results of this verification process and/or interview to authorized representatives. I do hereby agree to forever release and discharge our agent, Hirease, Inc. and their associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs and expenses, or any other charge or complaint arising from the retrieving and reporting of information.

IDENTIFYING INFORMATION FOR CONSUMER REPORTING AGENCY

(Please list at least 5 years of address history

Current Address: (street address) Number of years at address:

Notice to New York Applicants. Under Article 25 § 380-c(B2) of the NY General Business Law, you have the right, upon written request, to be informed whether or not an investigative consumer report was requested, and if such report was requested the name and address of the company to whom the request was made. Under § 380-g of the NY General Business Law, should a consumer report received by an employer contain criminal conviction information, the employer must provide you aprintedor electronic copy of Article 23-A of the NY Correction Law, which governs employment of persons previously convicted of one or more criminal offense. Have you ever been sanctioned, disciplined, debarred, and/or excluded by a duly authorized regulatory agency or are there any current restrictions or limits on If yes,please attach a complete explanation. Have you ever been convicted of any criminal violation of the law other than a minor traffic violation or are you now under pending investigation or charges If yes, please attach a complete explanation. *Without this information, we will be unable to properly identify you in the event we find adverse information during the course of our background investigation.