APPLICATION FORM

Address: 1818 New York Ave, Suite 225, Washington, DC 20002

Phone: 202-873-5155 | Email: intake@sr-institute.com
CONTRACTOR PROFILE SHEET
We consider all applicants for all positions without regards to race, color, religion, sex, national origin, age, marital or veteran status, handicap, or any other legally protected status for contractors.
Personal Information
Name

First NameMiddle InitialLast Name
Present Address:
Permanent Address:
Phone Number (Mobile):
Format: (000) 000-0000.
Alternate Phone Number:
Format: (000) 000-0000.
Educational Information

Educational Information

Rows	Name/Location	City & State	Attendance Dates	Degree Studied
High School
College

SYNERGY RECOVERY
-INSTITUTE
Address: 1818 New York Ave, Suite 225, Washington, DC 20002
Phone: 202-873-5155 | Email: intake@sr-institute.com
Work History (Current and Former Clients or Employers)

Work History (Current and Former Clients or Employers)

Rows	Dates of Service	Company Name & Address	Duties	Job Title	Reason for Leaving
1
2
3
4
5

1818 New York Avenue, NE, Suite 225, Washington, DC 20002 *** Phone: 202 873-5155
2

Address: 1818 New York Ave, Suite 225, Washington, DC 20002
Phone: 202-873-5155 | Email: intake@sr-institute.com
AUTHORIZATION
I certify that the facts contained in this form are true and complete to the best of my knowledge and understand that any falsified statements on this application shall be grounds for dismissal of contract agreement.
Applicant Name:

First NameLast Name
Applicant Signature:
Date:

MonthDayYear
Date
1818 New York Avenue, NE, Suite 225, Washington, DC 20002 *** Phone: 202-873-5155
3

SYNERGY RECOVERY - INSTITUTE
Address: 1818 New York Ave, Suite 225, Washington, DC 20002
Phone: 202-873-5155 | Email: intake@sr-institute.com
HIPAA-AGREEMENT OF CONFIDENTIALITY
I _________________________ undersigned understand the importance of observing strict, confidentiality polices. Therefore, I agree not to discuss/release any information obtained within the agency regarding any SYNERGY RECOVERY INSTITUTE LLC . client, his/her medical record, or any client's condition with any individual not directly associated with SYNERGY RECOVERY INSTITUTE LLC nor with other SYNERGY RECOVERY INSTITUTE LLC contractors, employees or other staff members who are not directly associated with that client.
I also agree that any information that is released regarding the client or the client's record will only be done with proper authorization and/or accordance with established agency policy for the release of the information.
My signature on this document indicates that I understand and agree to abide by the aforementioned polices, and that any breach in the aforementioned polices will result in the IMMEDIATE TERMINATION of my contract from SYNERGY RECOVERY INSTITUTE LLC.
Contractor Name

First NameLast Name
Contractor Signature
Date

MonthDayYear
Date
4

Address: 1818 New York Ave, Suite 225, Washington, DC 20002
Phone: 202-873-5155 | Email: intake@sr-institute.com
STANDARDS OF CONDUCT
The work rules and standards of conduct for SYNERGY RECOVERY INSTITUTE LLC. are important, and the Company regards them seriously. All independent contractors are required to become familiar with these rules and standards. In addition, independent contractors are expected to follow the rules and standards faithfully in working within their own scope of work and conducting SYNERGY RECOVERY INSTITUTE LLC. business. Any independent contractor who deviates from these rules and standards will be removed from service and contract terminated.
While not intended to list all the forms of behavior that are considered unacceptable while working with clients, the following are examples of rule infractions or misconduct that may result in contract termination:
- Theft or inappropriate removal or possession of property of the Company or others
- Falsification of notes or timekeeping records
- Working under the influence of alcohol, marijuana or illegal drugs
- Possession, distribution, sale, transfer, or use of alcohol or illegal drugs in the workplace
- Fighting or threatening violence at client homes, other facilities or in the community
- Boisterous or disruptive activity at client homes, other facilities or in the community
- Negligence or improper conduct leading to damage of Company-owned, customer-owned, or fellow-contractor-owned property
- Other disrespectful conduct
- Violation of safety or health rules
- Sexual or other unlawful or unwelcomed harassment
- Excessive absenteeism and/or any absence without notice
- Unauthorized disclosure of business "secrets" or confidential information
- Violation of any polies that contractors must follow
- Unsatisfactory conduct or unsatisfactory performance within the scope of work
Contractor Printed Name
Contractor Signature
Date

MonthDayYear
Date

Address: 1818 New York Ave, Suite 225, Washington, DC 20002
Phone: 202-873-5155 | Email: intake@sr-institute.com
Substance Abuse and Drug Testing Policy
SYNERGY RECOVERY INSTITUTE LLC. is committed to providing a safe working environment and to fostering the health and well-being of all independent contractors. That commitment is jeopardized when any SYNERGY RECOVERY INSTITUTE LLC. contractor uses illegal drugs while performing the scope of work at a client's home or other facility, reports to the client's homeor other facility under the influence, possesses, distributes or sells drugs at client's home orother facility or abuses alcohol, prescription drugs, or marijuana in a way that affects the scope of their job performance. Therefore, SYNERGY RECOVERY INSTITUTE LLC. has established the following Substance Abuse Policy:
It is a violation of company policy for any contractor to use, possess, sell, trade, offer for sale, or buy illegal drugs or otherwise engage in the illegal use of drugs while performing their scope of work at a client's home or other facility.
It is a violation of company policy for contractors to report to their site under the influence of illegal drugs, prescription drugs, marijuana, or alcohol.
It is a violation of the company policy for a contractor to use prescription drugs illegally. (However, nothing in this policy precludes the appropriate use oflegally prescribed medications, so long as their use does not impair the scope of the job performance.)
Everyone shares responsibility for maintaining a safe work environment; contract managers, agency employees and fellow contractors should encourage anyone whohas a substance abuse problem to seek help.
The goal of this policy is to maintain a safe, productive and drug-free environment. The intent of this policy is to send a clear message that the illegal use of drugs andthe abuse of alcohol or other recreational drugs are incompatible with contracting with SYNERGY RECOVERY INSTITUTE LLC.
Contractors can be subject to random drug testing at any time as a condition of continued contract work. Failure to comply may result in immediate contract termination.
By signing this policy, I certify that the policies have been received, read and understood. I further agree to submit to a drug test as requested as a condition of continued contract work. I also understand that failure to comply with a drug testing request, or a positive drug test result may lead to immediate termination of my contract.
Contractor Name:
Contractor Signature:
Date:

MonthDayYear
Date
6

SYNERGY RECOVERY
-INSTITUTE

Address: 1818 New York Ave, Suite 225, Washington, DC 20002
Phone: 202-873-5155 | Email: intake@sr-institute.com
Reporting Procedure
Employees, contractors, vendors, other third parties must immediately report suspected sexual abuse or misconduct to the HR Department or the CEO. It is not required to directly confront the person who is the source of the report, question or complaint before notifying any of the departments listed. SYNERGY RECOVERY INSTITUTE LLC. will take every reasonable measure to ensure that those named in complaint of misconduct or are too closely associated with those involved inthe complaint, will not be part of the investigative team.
Anti-retaliation and False Allegations
SYNERGY RECOVERY INSTITUTE LLC. prohibits retaliation made against any employee, contractor, volunteer, or other person who lodges a good faith complaint of sexual abuse or misconduct or who participates in any related investigation. Making knowingly false or malicious accusations of sexual abuse or misconduct can have serious consequences for those who are wrongly accused. SYNERGY RECOVERY INSTITUTE LLC. prohibits making false or malicious sexual misconduct allegations, aswell as deliberately providing false information during an investigation.
Anyone who violates this rule is subject to disciplinary action, up to and including termination of employment, termination of contract and/or criminal prosecution.
Investigation and Follow-up
SYNERGY RECOVERY INSTITUTE LLC. will take all allegations of sexual abuse or misconduct seriously and will promptly, thoroughly and equitably investigate whether misconduct has taken place. The organization may utilize an outside third party to conduct an investigation of misconduct. SYNERGY RECOVERY INSTITUTE LLC. will cooperate fully with any investigation conducted by law enforcement or other regulatory/protective services agencies. SYNERGY RECOVERY INSTITUTE LLC. will make every reasonable effort to keep the matters involved in the allegation as confidential as possible while still allowing for a prompt and thorough investigation.
Reporting to Law Enforcement or Appropriate Child or Adult Protective Services
SYNERGY RECOVERY INSTITUTE LLC. is committed to following the District of Columbia and federal legal requirements for reporting allegations or incidents of sexual abuse or misconduct toappropriate law enforcement and child or adult protective services organizations. It is the policy of SYNERGY RECOVERY INSTITUTE LLC. not to attempt to investigate or assess the validity or credibility of an
7

allegation of sexual or physical abuse as a condition before reporting the allegation to properlaw enforcement authorities or protective services organizations.
Employee, Contract and Volunteer Screening Selection
SYNERGY RECOVERY INSTITUTE LLC. is committed to maintaining a diligent screening program for all prospective employees, contractors, volunteers and others that may have interaction with those employed by, associating with or serviced by SYNERGY RECOVERY INSTITUTE LLC. The organization mayutilize a variety of methods of screening and selection, including, but not limited to applications, profiles, personal interviews, criminal background checks, sex offender background checks aswell as personal and professional references.
I acknowledge that I have read the Sexual Abuse and Misconduct Policy and/or had itexplained to me. I understand that it is my responsibility to abide by all rules contained in the policy.
Employee/Contractor/Volunteer Name:
Employee/Contractor/Volunteer Signature:
Date:

MonthDayYear
Date

SYNERGY RECOVERY
—INSTITUTE—
Address: 1818 New York Ave, Suite 225, Washington, DC 20002
Phone: 202-873-5155 | Email: intake@sr-institute.com
While it is not customary for Independent Contractors to complete an 1099 SYNERGY RECOVERY INSTITUTE LLC. is required to confirm that all staff are eligible to work in the United States.
Therefore, SYNERGY RECOVERY INSTITUTE LLC. requires all staff to supply authorized and approved documents listed on the Federal 1099 Form. Please complete the attached form Section 1 and supply proof of identity from the authorized list.
Human Resources Department
9
Should be Empty:

CONTRACTOR PROFILE SHEET

Personal Information

Educational Information

Work History (Current and Former Clients or Employers)

AUTHORIZATION

SYNERGY RECOVERY - INSTITUTE

HIPAA-AGREEMENT OF CONFIDENTIALITY

STANDARDS OF CONDUCT

Substance Abuse and Drug Testing Policy

Reporting Procedure

Anti-retaliation and False Allegations

Investigation and Follow-up

Reporting to Law Enforcement or Appropriate Child or Adult Protective Services

Employee, Contract and Volunteer Screening Selection