HOW DO WE CONTACT YOU? Patrice. 20 Frank Run Mailing Address* Midway. Florida City* GADSDEN.

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2 State of Florida EMPLOYMENT APPLICATION Equal Opportunity Employer/Affirmative Action Employer The State of Florida does not tolerate violence in the workplace. Where to Find Vacancy Information: On the Internet: One Stop Career Centers - Consult your local telephone directory or visit employflorida com State Agency Human Resources Offices FOR OFFICIAL USE ONLY Agency Authorized Signature Date Broadband Class/Code Status POSITION APPLIED FOR Position Title: EXECUTIVE DIRECTOR-FDLE Date Available: 05/27/2015 Position Number: Counties of Interest: Gadsden and Leon Minimum Acceptable Salary: GENERAL INSTRUCTIONS FOR COMPLETION OF APPLICATION: The application is T submitted until you have electronically signed it by entering your password. If the space provided is not sufficient for all information regarding past employment, education history, etc., attach a resume or other supporting documentation in the same format. All information provided will be a public record and will be released upon request, unless exempt or confidential by law. Applications and supporting documentation must be submitted, no later than 11:59 PM (ET) on the announced deadline date. If, because of a disability, you require a special accommodation to participate in the application and selection process, please notify the hiring authority in advance. All information you submit is subject to verification. EDUCATION HIGH SCHOOL: HOW DO WE CONTACT YOU? Patrice First Name* Middle Name People First Employee ID Number (if any) 20 Frank Run Mailing Address* Midway Florida City* State* GADSDEN (850) County Phone Number* Address Spicer Last Name* Zip Code* (702) Alternate Phone Number NAME/LOCATION OF SCHOOL Mitchell-Baker High School DIPLOMA RECEIVED: Yes YOUR NAME, IF DIFFERENT WHILE ATTENDING SCHOOL: COLLEGE, UNIVERSITY OR PROFESSIONAL SCHOOL: (TRANSCRIPTS MAY BE REQUIRED) NAME OF SCHOOL Valdosta State University Southwest GA Technical College LOCATION Valdosta, GA Thomasville, GA DATES OF ATTENDANCE CREDIT HOURS EARNED FROM TO QTR SEM 07/ / / / MAJOR / MIR COURSE OF STUDY Techinical Stud Clinical Lab Sc TYPE OF DEGREE EARNED Bachelors Associates Ashworth College Norcross, GA 01/ / MBA Healthcare In Progress YOUR NAME, IF DIFFERENT WHILE ATTENDING SCHOOL: LICENSURE, REGISTRATION, CERTIFICATION (EXAMPLES : Teacher Certification, RN, LPN, PE, CPA, etc.) LICENSE, REGISTRATION OR CERTIFICATION Number Date Received Expiration Date State Licensing Agency Medical Laboratory Technician /2000 ASCP Certified Nursing Assistant 07/1995 State of Georgia Driver license s (2)(a) F.S. 05/ /2015 FL OSHA certification 05/2001 Emergency Management Certification 04/2015 FEMA

3 JOB-RELATED TRAINING OR COURSE WORK: NAME OF SCHOOL LOCATION (VOCATIONAL, TRADE, GOVERNMENTAL, BUSINESS, ARMED FORCES, ETC.) DATES OF ATTENDANCE CREDIT HOURS EARNED COURSE OF STUDY TRAINING COMPLETED FROM TO CLASS CLOCK BRUNSWICK JCC BRUNSWICK, GA 02/ /1995 nurse assistant Yes YOUR NAME, IF DIFFERENT WHILE ATTENDING TRAINING: KWLEDGE / SKILLS / ABILITIES (KSAs) List KSAs you possess and believe relevant to the position you seek, such as operating heavy equipment, computer skills, fluency in language(s), etc. I have knowlege and experience with AHCA database systems Versa, Aspen and Sharepoint. I'm very skilled with Microsoft office especially word, excel and powerpoint. I have experience in the CLIA program and databases. I have extensive skills in customer service. I have worked in facility licensure for 9 years. I have 15 years experience in the clinical laboratory and quality control procedures.

4 PERIODS OF EMPLOYMENT Describe all work experience in detail, beginning with your current or most recent job. Include military service (indicate rank), internships and job-related volunteer work, if applicable. Indicate number of employees supervised. Use a separate block to describe each position or gap in employment. If needed, attach additional sheets, using the same format as on the application. All information in this section must be completed. Resumes may be attached to provide additional information. Name of Present or Past Employer: 1 Agency for Healthcare Administration 2727 Mahan Drive, Tallahassee FL US Health Srvs & Facil Consultant Mary Bowen 10/2006 Hours per Week: Duties and Responsibilities: Analyze, consultant and evaluate assisted living program and facilities based on Florida statutes and regulations for issue of licenses. Consult potential and current providers of procedures and regulation on attaining and maintaining licensure. Analyze, review, and process licensure applications. Compile and mail administrative notices. Prepare files for electronic scanning according to protocols. Represent the Agency at meetings, conferences, workshops, depositions and hearings as well as any related tasks. Work extensively with General Counsel to litigate non-compliant providers. 40 (850) Presently employed 2 Name of Previous Employer: Agency for Healthcare Administration 2727 Mahan Dr, Tallahassee FL US Biological Scientist III Patricia James (850) Duties and Responsibilities: 03/ /2006 Hours per Week: 40 Evaluate facilities eligibility to participate in the state laboratory program and federal CLIA program based on Florida statutes and CLIA regulation. Review proficiency participation to determine valid testing of medical specimens. Consult potential and current laboratories of procedures and regulation on attaining/maintaining licensure. Analyze, review, and process licensure applications. Compile and mail administrative notices. Prepare files for electronic scanning according to protocols. Represent the Agency at meetings, conferences, workshops, depositions and hearings as well as any related tasks. Promotion within the agency.

5 3 Name of Previous Employer: Doctors Laboratory 2906 Julia Drive Valdosta GA US Medical Lab Technician Chris DeMorow (229) Duties and Responsibilities: 08/ /2004 Hours per Week: Patrice Mickens Perform clinical laboratory tests in Chemistry, which included hormone testing, infectious disease testing (hepatitis and HIV) and other chemical normals of the blood. Also perform tests in Urinalysis and Hematology including Complete Blood Counts and Serology testing such as RPRs. Maintain quality control and quality assurance procedures in accordance to lab specifications. Maintain reagents and supplies 40 Married and relocated 4 Name of Previous Employer: Thomasville Family Medicine Center 951 South Broad Street Thomasville GA US Laboratory Manager Calvin Reams (229) / /2000 Hours per Week: 45 Patrice Mickens Duties and Responsibilities Perform venipunctures and tests in Hematology, Urinalysis, Chemistry, and Microbiology, using automation and manual methods in Physician Office Lab. Also perform quality control, maintain inventory, report lab results and other quality assurance procedures. Relocated for family emergency.

6 EXEMPTION FROM PUBLIC RECORDS DISCLOSURE ARE YOU A CURRENT OR FORMER LAW ENFORCEMENT OFFICER, OTHER COVERED EMPLOYEE**, OR THE SPOUSE OR CHILD OF ONE, WHOSE INFORMATION IS EXEMPT FROM PUBLIC RECORDS DISCLOSURE UNDER SECTION (4)(d), FLORIDA STATUTES (F.S.)?* **Other covered jobs include but are not limited to: correctional and correctional probation officers, firefighters, certain judges, assistant state attorneys, state attorneys, assistant and statewide prosecutors, personnel of the Department of Revenue or local governments whose responsibilities include revenue collection and enforcement or child support enforcement, and certain investigators in the Department of Children and Families [see F.S.]. BACKGROUND INFORMATION HAVE YOU EVER BEEN CONVICTED OF A FELONY OR A FIRST DEGREE MISDEMEAR?* If, what charges? Where? (City/State) Date: HAVE YOU EVER PLED LO CONTENDERE OR PLED GUILTY TO A CRIME WHICH IS A FELONY OR A FIRST DEGREE MISDEMEAR?* If, what charges? Where? (City/State) Date: HAVE YOU EVER HAD THE ADJUDICATION OF GUILT WITHELD FOR A CRIME WHICH IS A FELONY OR A FIRST DEGREE MISDEMEAR?* If, what charges? Where? (City/State) Date: TE: A answer to these questions will not automatically bar you from employment. The nature, job-relatedness, severity and date of the offense in relation to the position for which you are applying are considered [see , F.S.] CITIZENSHIP The state of Florida hires only U.S. citizens and lawfully authorized alien workers. You will be required to provide identification and either proof of citizenship or proof of authorization to work in the U.S. 1. ARE YOU A U.S. CITIZEN?* 2. IF, ARE YOU LEGALLY AUTHORIZED TO ACCEPT EMPLOYMENT WITH THE SPECIFIC HIRING AUTHORITY TO WHICH YOU ARE APPLYING?* RELATIVES TO YOUR KWLEDGE, DO YOU HAVE ANY RELATIVES WORKING IN THIS AGENCY?* SELECTIVE SERVICE SYSTEM REGISTRATION Section , Florida Statutes, prohibits employment by the State (including re-hire after a break in service) of any male born after October 1, 1962, who failed to register with the Selective Service System, under the provisions of the U.S. Military Selective Service Act, during the person's period of eligibility (ages 18 through 25). Additionally, if currently employed by the State, this law prohibits the promotion of such person. IF YOU ARE A MALE BORN ON OR AFTER OCTOBER 1, 1962, HAVE YOU REGISTERED WITH THE SELECTIVE SERVICE OR DO YOU HAVE PROOF OF AN EXEMPTION FROM THIS REQUIREMENT N/A (DOCUMENTATION MAY BE REQUIRED )?* CERTIFICATION I am aware that any omissions, falsifications, misstatements, or misrepresentations above may disqualify me for employment consideration and, if I am hired, may be grounds for termination at a later date. I understand that any information I give may be investigated as allowed by law. I consent to the release of information about my ability, employment history, and fitness for employment by employers, schools, law enforcement agencies, and other individuals and organizations to investigators, human resources staff, and other authorized employees of Florida state government for employment purposes. This consent shall continue to be effective during my employment if I am hired. I understand that applications submitted for state employment are public records. I certify that to the best of my knowledge and belief all of the statements contained herein and on any attachments are true, correct, complete, and made in good faith. SIGNED ELECTRONICALLY BY: Patrice Spicer 05/27/2015

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