201 Forest Avenue Phone: (401) 848-6000

201 Forest Avenue Phone: (401) 848-6000 P.O. Box 4007 Fax: (401) 848-7804 Middletown, RI 02842 APPLICATION FOR EMPLOYMENT Pre-Employment Questionnaire EQUAL OPPORTUNITY EMPLOYER Personal Data Date Name (Last, First, Middle) ______Social Security Number Position Applying For ______Address ______City State Zip Code ______Home Phone Cell Phone E-Mail

______If employed, can you provide proof of authorization to work in the U.S.? □ Yes □ No ______Referred by: □ Ad □ Friend □ Relative □ Agency □ Other ______Next of Kin: Name:______Address:______Phone #______Education Record High School Attended ______Address ______Did you graduate? □ Yes □ No If YES, What year did you graduate? ______College/University ______Address ______Degrees or Diplomas Years Attended 1 2 3 4 ______Graduate School ______Address ______Degrees or Diplomas Years Attended 1 2 3 4 ______Special Skills Summarize any special skills or qualifications that you acquired through employment or other experience: ______Employment History Begin with most recent employer. Attach additional sheet if needed: Employer Dates Employed ______Address ______Phone Ending Salary ______Title/Duties ______Supervisor/Contact Name ______Employer Dates Employed ______Address ______Phone Ending Salary ______Title/Duties ______Supervisor/Contact Name ______

Personal Data Have you ever been convicted of a felony? (A conviction will not necessarily bar you from employment) □ Yes □ No If ‘yes’, explain ) ______Proof of Valid Driver’s License □ Yes □ No Proof of Valid Auto Insurance □ Yes □ No Can you provide your driving record □ Yes □ No Have you been employed here before □ Yes □ No May we contact your current employer □ Yes □ No Date you are available for employment:______

Have you ever had any action taken on your clinical privileges (including voluntary suspension and non- renewal, in any state: □ Yes □ No If ‘yes’, explain ______

Have you ever had any action taken on your professional license in any state □ Yes □ No If ‘yes’, explain ______

Applicant’s Signature I certify that all of my answers given here are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand that neither this document nor any offer of employment from the employer constitutes an employment contract, unless a specific document to that effect is executed by the employer and employee in writing.

______Signature of Applicant Date

REFERENCE CHECK NewCare needs two (2) references

Applicant’s Name______

Company that you worked for______Telephone ______

Contact Person______

Dates of Employment______

Position Held______

Responsibilities/Duties______

THIS SECTION TO BE COMPLETED BY NEWCARE, LLC

Assessment of Skills – Rate 1-10 (10 being the highest) ______

Ability to work with other staff______

Attitude______

Attendance ______

Reason for Separation______

Would you re-hire? ______

Other information______

Completed by______Title______Date______

Applicant’s Authorization to release Information

I authorize NewCare, LLC to make a thorough investigation of my previous employment history as stated on my application for employment. I hereby release from liability or responsibility or individuals, establishments, employers, educational institutions and/or agencies supplying such information.

______Signature of Applicant Date REFERENCE CHECK NewCare needs two (2) references

Applicant’s Name______

Company that you worked for______Telephone ______

Contact Person______

Dates of Employment______

Position Held______

Responsibilities/Duties______

THIS SECTION TO BE COMPLETED BY NEWCARE, LLC

Assessment of Skills – Rate 1-10 (10 being the highest) ______

Ability to work with other staff______

Attitude______

Attendance ______

Reason for Separation______

Would you re-hire? ______

Other information______

Completed by______Title______Date______

Applicant’s Authorization to release Information

I authorize NewCare, LLC to make a thorough investigation of my previous employment history as stated on my application for employment. I hereby release from liability or responsibility or individuals, establishments, employers, educational institutions and/or agencies supplying such information.

______Signature of Applicant Date AVAILABILITY AGREEMENT

Name: ______

Position applying for: ______

Will this be your second job? ______

When are you available to start date ______? What hours and days of the week can you work?

DAY OF THE WEEK TIME AM/PM

SUNDAY MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY

Total hours per week that you are available? ______

What is your expected rate of pay?______

I agree to be available for work with NewCare for the above mentioned times.

______Signature Date CRIMINAL RECORDS CHECK

CONSENT AND DISCLAIMER FORM (TO BE FAXED BY THE EMPLOYER TO THE POLICE DEPARTMENT)

FULL NAME:______

MAIDEN NAME/ALIAS:______

ADDRESS:______

______

D.O.B.:______SS#:______RACE:______SEX:______

NAME & ADDRESS OF EMPLOYING AGENCY: NewCare, LLC 201 Forest Avenue Middletown, RI 02842

SIGNATURE OF EMPLOYER/SUPERVISOR:______

I am seeking employment with NewCare, LLC and I hereby direct and authorize the Middletown Police Department to review any criminal record that is on file in reference to me in accordance with R.I. General Laws Title 23 Chapters 17, 17.4 and 17.7. Any disqualifying information found will result in a letter to NewCare, LLC disqualifying me from said employment.

I hereby waive and release any and all manner of actions, cause of actions, and demands of every kind, nature and description arising from any release of criminal records and requests municipality and the employees of the Middletown Police Department in both law and equity which I may now have or in the future may have.

______of______Printed Name City

Personally appeared before me and made oath that the facts stated above are true.

______Signature of Applicant

NOTARY (To be completed & notarized prior to submission) For Notary use only

Sworn before me this ______day of______20______.

______Notary Public County My commission expires: ______