EDUCATION List all educational degrees & training you have received (List high school if no college). Degree Major School Name & Address Graduated Yr

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1 INDEPENDENT CONTRACTOR PROFESSIONAL REGISTRATION DATE Please check one Affiliate: Eastern PA Western PA MA CT NJ MD VA MI IL AZ LA General: LASTNAME FIRSTNAME MAIDEN EIN/SS NAME: NUMBER - - HIGHEST EDUCATION: Please check when available to work: Day 1st 2nd 3rd Sun REFERRED BY: Mon Tues PAY RANGE / SALARY: Wed Thurs DATE AVAILABLE TO START: Fri Sat (please check all that apply): C Will Travel Reliable Method of Transport Full Time Temp to Perm Per Diem Are you eligible to work in the United States? Main: ADDRESS: Yes No HOME# ( ) - WORK# ( ) - CELL # ( ) - BEEP # ( ) - EDUCATION List all educational degrees & training you have received (List high school if no college). Degree Major School Name & Address Graduated Yr 1 Y \ N 2 Y \ N 3 Y \ N CERTIFICATIONS \ LICENSES Certification / License Type: State Criminal / Child Abuse Check Child Abuse Check: Yes / No Criminal Check: Yes / No DMV Check: Yes / No Liability Insurance: Type: Type: Limit: Limit: State State

2 PROFESSIONAL HISTORY List below your work history, starting with most recent employer first: Start Date Mnth /Yr End Date Mnth /Yr Name and Address of Employer Start Salary End Salary Position Reason for Leaving CONTRACTING HISTORY List below other contracting or temporary agency work you have done. Date Month and Year Name and Address of Agency Location of Work Rate Position PROFESSIONAL REFERENCES (Requires at least 3) When Delta-T Group is attempting to staff you at a facility it is common for the facility to inquire about your previous work experience. Please help us develop your profile by supplying references from the facilities you listed above and/or on your resume the requested information about the facilities you have listed on your resume or application. Thank You. Facility Name Direct Supervisor & Title* Phone Number * Supply, at least one name who can provide Delta-T with a professional reference on you.

3 JOBS: Please check all job titles that you have held: ACTIVITIES SUPERVISOR ACTIVITIES THERAPIST ADDICTIONS COUNSELOR ADMINISTRATIVE ASSISTANT ADMISSIONS ART THERAPIST ASSISTANT NURSE MANAGER ASSOCIATE ADDICTION COUNSELOR BEHAVIORAL HEALTH SPECIALIST BOARD CERTIFIED PSYCHIATRIST BOARD ELIGIBLE PSYCHIATRIST BUSINESS MANAGER CAC DIPLOMAT CARE MANAGER SPECIALIST CASE MANAGER CASE SUPPORT ASSOCIATE CERTIFIED ADDICTIONS COUNSELOR CERTIFIED NURSING ASSISTANT CERTIFIED SOCIAL WORKER CTRS CERT THERAPEUTIC REC SPECLST CHARGE NURSE CHIEF EXECUTIVE OFFICER(MED) CHILD CARE TEACHER/ 32 HRS PER WEEK CHILD LIFE SPECIALIST CLINIC MANAGER CLINICAL CONSULTANT CLINICAL CLINICAL DIETITIAN CLINICAL MANAGER CLINICAL NURSE EDUCATOR CLINICAL NURSE SPECIALIST CLINICAL PHARMACIST CLINICAL PROCESSING TECHNICIAN CLINICAL PSYCHOLOGIST CLINICAL RN SPECIALIST CLINICAL SOCIAL WORK CLINICAL SPECIALIST CLINICAL SUPERVISOR COMMUNITY EDUCATOR COMMUNITY LIAISON NURSE COMMUNITY MOBILIZER COMMUNITY NURSING CARE COMMUNITY RELATIONS COUNSELOR CREATIVE ARTS THERAPIST CRITICAL CARE NURSE CRNA DANCE THERAPIST DEPARTMENT DIRECTOR DIRECTOR OF ADMISSIONS DIRECTOR OF AMBULATORY CARE SRVS DIRECTOR OF CHILD CARE SERVICES DIRECTOR OF HEALTH INFORMATION MGMT DIRECTOR OF MEDICAL SERVICES DIRECTOR OF NURSING DIRECTOR OF PSYCHIATRY DIRECTOR OF PSYCHOLOGY DIRECTOR OF QUALITY MANAGEMENT DIRECTOR OF SOCIAL SERVICES DIRECTOR OUTCOME MANAGEMENT DIRECTOR-MANAGED CARE DRUG & ALCOHOL COUNSELOR DRUG MEDICAL OUTPATIENT EMERGENCY NURSE EXECUTIVE DIRECTOR FAMILY THERAPIST FOSTER CARE COUNSELOR GERI-PSYCH GROUP COUNSELOR GROUP THERAPIST HOME CARE HOME HEALTH AIDE HOME HEALTH DIRECTOR HOSPICE DIRECTOR IV TEAM NURSE ICU RN INDIVIDUAL THERAPIST INTAKE LICENSED PRACTICAL NURSE (LPN) LICENSED SOCIAL WORKER MANAGER III/HEAD NURSE MEDICAL DOCTOR MENTAL HEALTH CASE MANAGER MENTAL HEALTH COUNSELOR MENTAL HEALTH PROFESSIONALS MENTAL HEALTH SUPPORT WORKER MENTAL HEALTH TECHNICIAN MENTAL HEALTH THERAPIST MENTAL HEALTH WORKER MENTAL RETARDATION COUNSELOR MENTAL RETARDATION THERAPIST MOBILE THERAPIST MOVEMENT THERAPIST MUSIC THERAPIST NEEDS ASSESSMENT COUNSELOR NEONATAL SOCIAL WORKER NURSE NURSE DIRECTOR NURSE MANAGER NURSE PRACTITIONER NURSING AIDE NURSING EDUCATOR NURSING HOME ADMINISTRATOR NURSING SERVICE NURSING SUPERVISOR OFFICE MANAGER OUTREACH WORKER (ORW) PHARMACIST PHARMACY ASSISTANT PHARMACY DIRECTOR PHARMACY MANAGER PHARMACY SUPERVISOR PHARMACY TECHNICIAN PRIVATE PRACTICE THERAPIST PROFESSIONAL REVIEW SUPERVISOR PROJECT DIR SUBSTANCE ABUSE PSYCHIATRIC AIDE PSYCHIATRIC NURSE (RN) PSYCHIATRIC TECHNICIAN PSYCHIATRIST PSYCHOLOGIST PSYCHOTHERAPIST R.N. DIRECTOR EDUCATIONAL SERVICES R.N./L.V.N. RECREATION THERAPIST RECREATIONAL AIDE RECREATIONAL THERAPIST REGIONAL ADMINISTRATOR RESIDENTIAL AIDE RESIDENTIAL COUNSELOR SOCIAL SERVICES SOCIAL WORKER SOCIAL WORKER/CASE MANAGER SOCIAL WORKER/CLINICAL SOCIAL WORKER/DISCHARGE PLANNER SOCIAL WORKER/MEDICAL SOCIAL WORKER/PSYCHIATRIC SOCIAL WORKER/UTILIZATION REVIEW SPECIAL EDUCATION TEACHER SUBSTANCE ABUSE COUNSELOR SUPERVISOR TEACHER THERAPEUTIC STAFF SUPPORT THERAPIST UTILIZATION MANAGEMENT UTILIZATION REVIEW SPECIALIST VICE PRESIDENT OF CLINICAL SERVICES OTHER:

4 SKILLS: Please indicate your experience level for each skill area, where 1=MINIMIAL EXPERIENCE, 2=MODERATE EXPERIENCE, 3=STRONG EXPERIENCE. Do not put anything in areas you have NO experience. GENERAL SKILLS: UTILIZATION REVIEW MAN CARE SETTING MOVEMENT THERAPY: ADLS (ASSISTED DAILY LIVING SKILLS) VOCATIONAL COUNSELING MUSIC THERAPY ASSESSMENTS WHEELCHAIR TRAINED CREATIVE ARTS THERAPY BEHAVIOR MANAGEMENT MUSIC THERAPY GUITAR BEHAVIORAL THERAPY MUSIC THERAPY VIOLIN CARE MANAGEMENT SUBSTANCE ABUSE: DANCE THERAPY CASE MANAGEMENT 12 STEP TREATMENT ART THERAPY CASE NOTES ADDICTIONS COUNSELING CHARTING ADDICTIONS THERAPY CLINICAL CONSULTATION ALCOHOL COUSELING CLINICAL SOCIAL WORK DISEASE MODEL TREATMENT AGE GROUP EXPERIENCE: COGNITIVE THERAPY DRUG & ALCOHOL COUNSELING GERIATRIC COMPUTER LITERATE DRUG AND ALCOHOL SERVICES ELDERLY CONSULTING DRUG COUNSELING ADULT COUPLES MICA ADOLESCENT COURT ADJUDICATED SUBSTANCE ABUSE COUNSELING PEDIATRIC CREATIVE ARTS THERAPY SUBSTANCE ABUSE THERAPY MIXED CRISIS INTERVENTION COUPLES DATA ENTRY WRAP PROGRAMS: DETOX/METHADONE CLINIC PSYCHIATRY LANGUAGES: DIAGNOSTIC ASSESSMENTS PSYCHIATIC MEDICAL DOCTOR SPANISH DISCHARGE PLANNING PSYCHIATRIC EVALUATIONS FRENCH DOCUMENTATION MEDICATION MANAGEMENT GERMAN DRUG & ALCOHOL COUNSELING GERIATRIC PSYCHIATRY ITALIAN EAP ADULT PSYCHIATRY AMERICAN SIGN LANGUAGE EARLY INTERVENTION CHILD PSYCHIATRY FAMILY THERAPY ADOLESCENT PSYCHIATRY FACILITY TYPE / SETTING EXPERIENCE: GROUP THERAPY NEUROPSYCHIATRY HOSPITAL HOME VISITS PSYCHIATRY RESIDENCY INPATIENT HUMAN SERVICES PSYCHIATRIC NURSING OUTPATIENT INSPECTION PREPARATION PSYCHOLOGY COMMUNITY CENTER MANAGED CARE PSYCHOLOGICAL SERVICES NURSING HOME MANAGEMENT INDIVIDUAL PSYCHOLOGY PARTIAL HOSPITAL MARRIAGE THERAPY CLINICAL PSYCHOLOGY RESIDENTIAL HOME MDS PAPERWORK PSYCHOLOGY CLINICAL HOSPITAL REHAB MEDICATION MANAGEMENT PSYCHOTHERAPY DETOXIFICATION /METHADONE CLINIC MENTAL HEALTH ADMINISTRATION PSYCHOLOGICAL TESTING SCHOOL MENTAL HEALTH THERAPY PSYCHOTHERAPEUTIC SERVICES FOSTER CARE / SCOH MENTOR DRUG AND ALCOHOL SERVICES HOSPICE MOBILE THERAPY 3RD PARTY PAYMENTS HOME CARE NURSING FAMILY SERVICES OBRA REGULATIONS SOCIAL SERVICES: OCCUPATIONAL THERAPY AGING SERVICES ONE ON ONE THERAPY CASE REPORTING OUTREACH WORKER COMMUNITY RESOURCE PLANNING PHYSICAL RESTRAINT EXP INDIVIDUAL CARE PLAN GENDER: PHYSICAL THERAPY INTERVENTION GENDER MALE PLAY THERAPY LONG RANGE PLANNING GENDER FEMALE PRIVATE PRACTICE THERAPY MEDICAL SOCIAL SERVICES PSYCHOLOGY MEDICAL SOCIAL WORK OTHER (please write in): PSYCHOSOCIAL ASSESSMENTS REFERRAL SERVICES QA CLINICAL SETTING SOCIAL SERVICES QA MANAGED CARE SETTING SOCIAL WORK CLINICAL REGULATION KNOWLEDGE SOCIAL WORK DISCHARE PLANNING SPECIAL EDUCATION SOCIAL WORK HOME VISITS SPEECH THERAPY SOCIAL WORK CASE MANAGEMENT SUICIDE CRISIS COUNSELING TEACHING THERAPEUTIC STAFF SUPPORT TREATMENT PLANNING TRIAGE UTILIZATION REVIEW CLIN SETTING

5 SKILLS, continued: Please indicate your experience level for each skill area, where 1=MINIMIAL EXPERIENCE, 2=MODERATE EXPERIENCE, 3=STRONG EXPERIENCE. Do not put anything in areas you have NO experience. POPULATION EXPERIENCE: PSYCHIATRIC POP. MENTAL RETARDATION POP. DRUGS & ALCOHOL POP. MENTAL HEALTH POP. AT RISK POP. MICA POP. MEDICAL POP. SCOH POP FOSTER CARE POP. PHYSICALLY DISABLED POP. COURT ADJUDICATED POP. AUTISM POP. SPECIAL EDUCATION POP HIV POP. ONCOLOGY POP. RECREATIONAL THERAPY ACTIVITIES THERAPY EDUCATION PHYSICAL DISABILITY PHYSICAL EDUCATION RECREATION AIDE (NONDEGREED) RECREATION SPECIALIST RECREATIONAL ACTIVITIES THERAPY PHARMACY JOB DETAIL: PHARMACY SERVICES PHARMACY INDUSTRY PHARMACY HOSPITAL PHARMACY INFUSION PHARMACY HOME CARE PHARMACY RETAIL PHARMACY LONG TERM CARE PHARMACY CONSULTING FILLING PRESCRIPTIONS DISPENSING MEDICATIONS ORDER ENTRY NURSING HOME CHARTS I.V. T.P.N. CHEMOTHERAPY PEDIATRICS NICU PUMPS COMPOUNDING

6 PROFESSIONAL INFORMATION SURVEY This information will better help us understand and service the professionals that contract through Delta-T Group. HOW TO COMPLETE: If for example last year you spent 80% of your time seeing patients in your own private practice and you worked 20% of your time with other staffing agencies to supplement your income you would put 80% in the private practice category and 20% in the Agencies/Brokers category. HOW YOU SPEND YOUR WORK TIME Current Previous Year Year* % of Work Time Spent: Private Practice Full-Time Employment Part-Time Employment Independent Contractor Staffing Agencies/ Brokers Total Work Time 100% 100% For current year please estimate your anticipated sources of income. What type of professional listings do you maintain (yellow pages, professional associations, professional directories) Can you provide a copy of this or instruct us where we can get it (if yes please do). Yes / No Describe your sole practice or other independent business activities such as consulting, private practice, training, et cetera. Also describe other groups/organizations that you have contracts with to provide services to (no names are necessary). Can you provide a business card, letterhead or other material showing your business activity(if yes please do). Yes / No What type of courses, professional education or continuing education have you taken and paid for in the past twelve months. Also include any other types of investments you have made in your professional career: Please provide your business name, address and telephone number: If you are a sole proprietor or self-employed professional and do not currently have a business name, other than your name, respond using your name, and the address and phone number used for your business. In Case of Emergency Notify Name Address Phone # Have any professional liability claims been made against you in the past five years?( YES / NO) If yes, explain: Have you ever been convicted of a crime ( YES / NO) If yes, Explain: NOTE: Massachusetts and City of Philadelphia Independent Contractors do not need to respond to this question in accordance with State and local laws. If other States, municipalities or local laws prohibit this question, you do not need to respond. A CONVICTION WILL NOT AUTOMATICALLY DISQUALIFIY YOU FROM CONSIDERATION FOR REFERRAL OPPORTUNITIES, UNLESS MANDATED BY LAW. I consent to the release, to any person of Delta-T Group and its Affiliates, of all information that is required by Delta-T to provide to a Client, to the extent permitted by law, my professional qualifications. I release Delta-T Group and its Affiliates and their employees and agents from any liability for their acts performed in good faith and without malice in obtaining information and evaluating my application. I understand and agree that my relationship with Delta-T Group is as a self-employed independent contractor and that my completion of this application is in no way a guarantee of any referrals or opportunities. By signing below, I certify that all information provided by me to Delta-T Group is true and accurate. I understand that any false or misleading statements that I make herein or at any point during my application process, may disqualify me from consideration for referrals and/or from continuing to perform services if actively referred, and may result in immediate termination of our relationship and of the Services Agreement. Signature: DATE