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1 APPLICATION FOR EMPLOYMENT: PLEASE PRINT Arizona Health Care Contract Management Services, Inc A Human Services Management Corporation 110 W. Camelback Road, Ste. 200 Phoenix, Arizona (602) FAX (602) Arizona Health Care Contract Management Services is an Equal Opportunity Employer Name: Last First MI Address: Street, PO Box City State Zip Home Have you ever been known by any other name? Yes Business _ No If yes, specify: Social Security Number: Driver's License Number: State: Expires: EMPLOYMENT DESIRED Type of position desired: Status Status preferred: Full-Time Part-Time Pool Permanent Temporary Hours/shift preferred: Days: Evenings: Nights: Weekends: No Preference: Date a Date available: Salary expectations: Please describe any special qualifications you have for this position: Referred by: Have you ever worked for this company before? Yes No If yes, when? Where?

2 APPLICATION FOR EMPLOYMENT PAGE 2 BACKGROUND Have Have you been dismissed or asked to resign from any employment? Yes No If yes, please explain including dates, places, and reasons Did an Did any dismissal or requested resignation involve allegations of client abuse? Yes No If yes, please explain including dates, places, and reasons: Have Have you ever been convicted of a felony? Yes No (Conviction will not necessarily disqualify you from employment.) If yes, please explain including dates, places, and reasons: Have Have you ever been convicted of a misdemeanor? Yes No If yes, please explain including dates, places, and reasons: Have Have you ever been convicted of any traffic violations? Yes No If yes, please explain including dates, places, and reasons: Have Have you ever been the subject of proceedings to suspend or revoke any professional license or certification? Yes No If yes, please explain including dates, places, and reasons: Have Have you served in the Armed Forces? Yes No Branc Branch of Service: Rank: Dates Dates of Service: Type Type of Discharge: EDUCATION Type of School Name & Location of School From Month/Year To Month/Year Credit Hours Received Degree or Diploma Received Major Subjects High School Trade or Business School College or University Graduate or Professional School

3 APPLICATION FOR EMPLOYMENT PAGE 3 PROFESSIONAL LICENSES AND CERTIFICATIONS License/Certificate Number Field or Specialty Agency and State Issued By Date of Expiration EMPLOYMENT HISTORY Name and Address of Employer Dates Worked (Month/Year) Salary Position Reason for Leaving REFERENCES Name Address Telephone Yrs. Known Relationship

4 APPLICATION FOR EMPLOYMENT PAGE 4 ARIZONA HEALTH CARE CONTRACT MANAGEMENT SERVICES, INC. ("AHCCMS"), is an Equal Opportunity Employer and selects employees regardless of race, color, religion, sex, national origin, age, disability, or other protected groups under Local, State or Federal Equal Opportunity Laws. 1. I understand and agree that any material misrepresentation or omission of fact in my application will render this application void and may result in refusal to employ me or, if hired, termination of my employment. 2. I authorize AHCCMS to make a thorough investigation of my entire work history, to verify all data given in my application for employment, related documents, or oral interviews, and to contact my former employers, references, consumer credit reporting agencies, and any other persons. I recognize and acknowledge that any such information, including without limitation background information and consumer credit reports, may be the basis for declining the employment applied for or, if hired, for terminating the employment. I request and authorize all persons so contacted to furnish the information so requested and, in consideration for so doing, hereby release any persons furnishing or receiving such information from all liability which might arise out of the communication so made or the information so furnished. 3. I agree that, if given a conditional offer of employment, I will provide, and authorize any physician or hospital to release, any information which may be necessary to determining my ability to perform the duties of the job for which I have been offered employment. 4. I agree to take a medical examination by a qualified physician at the discretion of AHCCMS, after a conditional offer of employment has been made by AHCCMS. 5. I understand and agree that any employment offered pursuant to this application will be at-will, terminable by either party at any time with or without reason, with or without notice, and with or without procedural formality or progressive discipline. I understand and agree that no representation, written or oral, express or implied, including without limitation those contained in any employment manuals or handbooks that may be distributed to me during the course of my employment, shall form a contract between me and AHCCMS so as to alter the at-will character of my employment. I further understand and agree that no person at AHCCMS, other than the President, has any authority to make any promise or representation to alter the at-will character of my employment. 6. I understand and agree that, if offered employment hereunder, such employment shall be subject to the reasonable rules and regulations of AHCCMS as issued and changed from time to time. 7. I understand and agree that AHCCMS may at times require me to work overtime, work on holidays, change the hours and/or days I am scheduled to work, or require me to work a schedule other than that for which I was originally hired, and I accept these as conditions of my continuing employment. 8. I understand and agree that AHCCMS may change my job title, assigned duties, wages, benefits, place of employment, and/or other conditions of employment at any time, and I accept these as conditions of my continuing employment. 9. I understand and agree that a condition of my employment shall be to maintain a valid Arizona Drivers License and clearance as an approved driver by the AHCCMS insurance carrier, if my job description requires driving to conduct AHCCMS business. 10. I understand and agree that this is an application for employment, and that no employment contract is offered or implied. I have read, understand, and agree to the above conditions. Signature: Date: THIS APPLICATION WILL BE KEPT IN OUR ACTIVE FILE FOR THIRTY DAYS. APPLICATION AFTER THAT TIME BY REAPPLYING IN PERSON. YOU MUST REACTIVATE YOUR

5 ARIZONA HEALTH CARE CONTRACT MANAGEMENT SERVICES, INC. A Human Services Management Corporation As an individual interested in employment with Arizona Health Care Contract Management Services, Inc. (AHCCMS), you should know that we are a private, for-profit agency that provides behavioral health services to adults who are seriously mentally ill or have developmental disabilities. Throughout its history, AHCCMS has demonstrated an ability to develop and operate unique and innovative programs designed to serve the hard to place individuals with multiple problems and/or disabilities; its mission is to provide those programs in an ethical, conscientious, and cost-efficient manner. AHCCMS supports adherence to the principles of normalization; is committed to promoting the integrity, self-reliance and well-being of each client; and works to ensure the protection of the clients rights while treating them with respect, dignity and compassion. Employment with AHCCMS is at will which means that either you or AHCCMS may terminate the employment relationship with or without reason at any time. An employee s job responsibilities, and any written job description, may also be changed at any time. As an employee, you are expected to be prepared to work the days and shifts assigned by your supervisor. The conditions of employment are subject to the laws and policies of federal, state and regulatory agencies, as well as to the standards set by this Company. On the first day of New Employee Orientation, you will be asked to provide: 1. Proper identification to prove your ability to meet the age requirements specified by the State Regulatory Agencies (mm. 21 years of age for Department of Economic Security programs, and for Office of Behavioral Health Licensure programs). 2. Proof of your ability to work legally in the United States (Social Security card, Passport, Certificate of Naturalization, Alien Registration card, etc.). 3. Proof of Education: mm. G.E.D. (Graduate Equivalency Diploma). 4. A current, valid State of Arizona Driver s License and a current (39 month) Motor Vehicle Report for individuals hired in a position with client care responsibilities. In addition, your completed employment application should indicate your ability to meet the requirements of the posted job description. If you are unable to provide verification that you meet these requirements, you may not accept a position with AHCCMS. The following items may also affect your employment: Automobile Insurance: Because of contractual regulatory obligations, staff working in AHCCMS programs which do not have a company vehicle on site may be required to use their personal automobiles to conduct company business. Employees using their personal vehicle must carry a minimum of $15,000 per person/$30,000 per occurrence for Bodily Injury Liability and $10,000 per occurrence for Property Damage Liability. In addition, AHCCMS must be named on your Certificate of Insurance. If your position requires use of your personal vehicle, you must provide a Certificate of Insurance issued to AHCCMS within two weeks of your date of hire and/or before you use your personal vehicle for company business. AHCCMS provides reimbursement for travel related to official company business. Personal vehicles must be in safe working order and have operable seat belts, adequate air conditioning and heating. Background Investigations and Fingerprinting: AHCCMS is mandated by licensing regulations to conduct background investigations and to submit the fingerprints of all individuals who work in a DD Program. Previous employment will be verified and character references are required. An inability or refusal to provide references/employment history provides a basis for declining or terminating employment of any individual. In order to insure the safety of our clients, fellow staff and visitors, AHCCMS also completes complete background investigations (which may include fingerprinting) for all potential employees for non DD Programs, provided the potential employee has properly authorized the background check/criminal records check. Eligibility for Benefits: All full-time employees are eligible for medical, dental and life insurance benefits the first of the month following 90 days of employment. Employees share in the cost of these benefits at a rate dependant upon the plan selected. Available benefit packages are reviewed during orientation. Physical Examinations and TB Screens: Potential employees who have been conditionally hired to work

6 directly with clients on a regular basis must undergo a medical examination or provide documentation of an examination completed prior to employment beginning to verify that the potential employee if free of any and all disease that would pose a significant health and safety risk and that cannot be eliminated or reduced by reasonable accommodations. TB screens must be performed annually. AHCCMS provides for these examinations through Concentra Medical Centers at no cost to the employee/potential employee unless the employee fails to follow through on instructions provided by the examiners. I have read and understand the responsibility of employment as indicated above. Signature of Applicant: Date: PAGE 5

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