APPLICATION FOR EMPLOYMENT

W e consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, m arital or veteran status, sexual orientation, or any other legally protected status. (PLEASE PRINT)
Position(s) Applied For Date of Application

How Did You Learn About Us? 9 Advertisement 9 Employment Agency 9 Friend 9 Relative 9 Walk-In 9 Other 9 CNS Employee [Name]

Last Name

First Name

Middle Name

Address

Number

Street

City

State

Zip Code

Telephone Number

Cell Phone Number

E-Mail Address

List all other nam es by which you have ever worked or been educated:___________________________ _____________________________________________________________________________________
(Note: This information is only necessary for verification of your prior work history and education.)

Are you 18 years of age or older? Have you ever filed an application with us before? If Yes, give date ________________ Have you ever been em ployed with us before?

No _____ Yes _____ No _____ Yes _____

No _____ Yes _____

If Yes, give date ________________ and position _______________________________ Are you currently em ployed? May we contact your present em ployer? Can you provide proof of authorization to work in the U.S.? On what date would you be available to work? Are you available to work: 9 Full Tim e 9 Part Tim e 9 Tem porary 9 Other No _____ Yes _____ No _____ Yes _____ No _____ Yes _____ No _____ Yes _____ No _____ Yes _____ No _____ Yes _____

Are you currently on "lay-off" status and subject to recall? Can you travel if a position requires it? Are you willing to work overtim e, if a position requires it?

WE ARE AN EQUAL OPPORTUNITY EMPLOYER

EMPLOYMENT EXPERIENCE
Start with your present or last job. Include any job related m ilitary service assignm ents. Please indicate if term ination was voluntary or involuntary, and your exact reasons for leaving.

1. Job Title: Employer Address

Dates Employed From To

Work Performed

Hourly Rate/Salary Phone Number(s) Supervisor Reason for Leaving Starting Final

2. Job Title: Employer Address

Dates Employed From To

Work Performed

Hourly Rate/Salary Phone Number(s) Supervisor Reason for Leaving Starting Final

3. Job Title: Employer Address

Dates Employed From To

Work Performed

Hourly Rate/Salary Phone Number(s) Supervisor Reason for Leaving Starting Final

4. Job Title: Employer Address

Dates Employed From To

Work Performed

Hourly Rate/Salary Phone Number(s) Supervisor Reason for Leaving Starting Final

If you need additional space, please continue on a separate sheet of paper.

Please account for any tim e you were not em ployed in the last 10 years, after leaving school (you need not list any unem ployed periods of two m onths or less). TIME PERIOD REASON(S) UNEMPLOYED

EDUCATION, TRAINING AND EXPERIENCE

Nam e and Address of School Elem entary School High School Course of Study Years Com pleted Diplom a Degree

Undergraduate College Graduate Professional Other (Specify) Do you speak, read and/or write any foreign languages? If yes, please list the language(s) and your proficiency below: FLUENT Speak Read W rite Do you have any other experience, training, qualifications or skills which you feel m ake you especially suited for work at CNS? If so, please explain: GOOD No _____ Yes _____

FAIR

Answer the following question if you are applying for a professional position.
Are you licensed/certified for the job applied for? If yes, please com plete the following: License/Certification Type Registration No. Issuing State or Agency Expiration Date No _____ Yes _____

MISCELLANEOUS
Do you have any com m itm ents to another entity, business, or person that m ight affect your em ploym ent with our com pany? No _____ Yes _____ If yes, please explain fully:

PERFORMANCE OF JOB-RELATED FUNCTIONS

I have read the attached job description for ____________________________________ before com pleting this section. No _____ Yes _____

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accom m odation? No _____ Yes _____ If no, describe the functions that cannot be perform ed:

(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)

Is there any reason why you, when perform ing your duties, would pose a direct threat to the health or safety of yourself or others in the workplace? No _____ Yes _____ If yes, describe fully:

Do you take drugs or m edication, legal or illegal, which m ight im pair your job perform ance? No _____ Yes _____ Do you use alcohol to the extent that it would im pair your job perform ance? If yes, describe fully: No _____ Yes _____

Are you able to adhere to the com panys attendance requirem ents? If no, describe fully:

No _____ Yes _____

CRIMINAL MATTERS
Have you ever been convicted of (or pleaded guilty or nolo contendere to) a crim e? (Do not identify m arijuana-related m isdem eanor convictions occurring m ore than two years ago or convictions for which the crim inal record has been expunged, sealed or eradicated by the court, or m isdem eanor convictions for which any probation has been com pleted and the case dism issed by the court.) (NOTE: All crim inal convictions after the age of 18, whether expunged, sealed, or eradicated will be reviewed by Departm ent of Social Services and m ay disqualify you from em ploym ent, delay your hire date, or require you to obtain an exem ption from Departm ent of Social Services.) Num ber No _____ Yes _____ of tim es_______ Did the conviction(s) (or guilty or nolo contendere plea) result in im prisonm ent? No _____ Yes _____ Num ber of tim es_______

Explain fully: (A conviction, or guilty, or nolo contendere plea will not necessarily disqualify an applicant.)

Are you currently charged with an unresolved crim inal charge (a charge which has not yet resulted in a plea, trial, or a dropping of the charge, or for which you are out on bail or on your own recognizance pending trial)? No _____ Yes _____ Explain fully: (A charge will not necessarily disqualify an applicant.)

REFERENCES
Give the nam es of three persons not related to you whom you have known at least one year. NAME 1. 2. 3. ADDRESS PHONE YEARS ACQUAINTED

List any friends or relatives that are current or past em ployees of CNS:

AUTHORIZATION
IMPORTANT (Please read carefully and initial each paragraph before signing) "I declare under penalty of perjury that the facts contained in this application or any resume or other documentation submitted are true and complete to the best of my knowledge. I understand that any false information or significant omissions will disqualify me from further consideration for employment, and will be justification for my dismissal from employment, if discovered at a later date." ______ Initials "I authorize the investigation of all statements contained in this application (and accompanying resume, if any). I further authorize any person, school, current employer (except as expressly noted), past employer(s), consumer reporting agency and organizations, whether or not named in this application form (and resume, if any), to provide the company with records, information and opinion that may be useful in making a hiring decision. I release all such informants and the company from all liability for any decision, claim or damage that may result from furnishing and/or relying on such information and opinion (which is truthful or made in good faith) to you. _____ Initials "I agree to immediately notify the company if I should be convicted of any crime while my job application is pending or during my period of employment, if hired." _____ Initials "I give permission for a pre-employment drug/alcohol screening exam and, if the company makes a conditional job offer, I give permission for a criminal record clearance (fingerprints), and for a fitness for duty physical examination. I also consent to the appropriate release of any and all medical information, as may be deemed necessary to determine employment eligibility. _____ Initials "I understand that, if hired, I may not hold other employment, nor engage in other activities that create a conflict of interest with my position with the company unless given permission in writing by the company." _____ Initials I understand that, if hired, my name, birth date, and social security number will be verified through the Social Security Administrations E-Verify System. _____ Initials

AGREEMENT FOR AT-WILL EMPLOYMENT

"If I become employed, in consideration of my employment, I agree that my employment will be at-will, and may be terminated with or without cause, and with or without notice, at any time at the option of myself or the company. Only the President of the Company has the authority to enter into an employment agreement for a specified period of time or for termination only for cause, and any such agreement must be in writing. I understand and acknowledge that this constitutes the entire agreement between me and the company regarding the term of my employment and supersedes any other oral or written agreement. _____ Initials

COMPLIANCE WITH RULES

If I become employed, in consideration of my employment, I agree to comply with the rules regulations, policies and procedures of the company. _____ Initials

PRE-EMPLOYMENT DOCUMENTS
If offered employment, I understand that I will be required to review, complete and execute various employment documents (including, but not limited to, this application, employee handbook and employee handbook receipt form, confidentiality and employee ethics agreements), and agree that the process of my being hired will not be complete until all employment documents have been signed. _____ Initials

Date

Signature

cnsapp-CA rev. 11/11

Centre for Neuro Skills CNS - Bakersfield 2658 Mt. Vernon Avenue Bakersfield, CA 93306 (805) 872-3408 (800) 922-4994 FAX: (805) 872-5150

http://www.neuroskills.com CNS - Texas 1320 W . W alnut Hill Lane Irving, TX 75038 (972) 580-8500 (800) 554-5448 FAX: (972) 255-3162

cns@ neuroskills.com CNS - Encino 16542 Ventura Blvd, Suite 500 Encino, CA 91436 (818) 783-3800 (800) 992-6752 FAX: (818) 783-8412

APPLICANT/EMPLOYEE NOTIFICATION
Centre for Neuro Skills (the Company) requires that you have a pre-employment drug/alcohol test and/or post-offer fitness for duty physical examination. This is a screening test to determine your fitness to perform job assignments without undue hazard to yourself, patients, or fellow employees. The health care personnel who perform these tests are acting for this purpose only. Therefore, these tests should not be interpreted as either a complete physical examination or used as a substitute for such examinations. At your request, the Company will provide your doctor with information concerning the examinations we have performed. * * * * I have read the above notification and understand that the pre-employment, post-offer, and/or update/periodic tests required by the Company are for the purpose of determining my fitness to perform the job only.

Applicant/Employee Print Name Applicant/Employee Signature

Date

Witness Print Name

Witness Signature

Date

INFORMED CONSENT STATEMENT ON DRUG/ALCOHOL TESTING

I understand that as part of the pre-employment evaluation process and the periodic/ random drug/alcohol testing program with Centre for Neuro Skills (the Company) I will be required to provide a body fluid specimen to be analyzed for the presence of: marijuana, cocaine, opiates, amphetamines, phencyclidine (PCP), barbiturates, benzodiazepines, methadone, methaqualone, propoxyphene, alcohol and other substances as deemed necessary by the Company. I understand that not satisfactorily passing a drug test will be cause of rejection of my employment application or termination of my employment. I understand that these are necessary due to the nature of the work I will be doing and the need to maintain a high level of health and safety for Company patients and employees. I have read the above and I certify that I understand the content of this document. I further understand that this authorization will remain in effect until my employment is terminated.

Applicant/Employee Print Name Applicant/Employee Signature

Date

Witness Print Name

Witness Signature

Date

EMPLOYEES NAME:___________________________SS#:____________________

DISCLOSURE AUTHORIZATION AND RELEASE

I hereby authorize any person, school, current em ployer (except as expressly noted), past em ployer(s), consum er reporting agency and organizations, whether or not nam ed in m y application form (and resum e, if any) to provide any pertinent inform ation, including any inform ation or records regarding m y em ploym ent, job perform ance, and related m atters, to Centre for Neuro Skills (CNS) and its designated em ployees, representatives, and agents. This inform ation m ay be provided either verbally or in writing. In addition to authorizing the disclosure and release of any inform ation regarding m y em ploym ent, I hereby fully waive any rights or claim s I have or m ay have against any person or persons who provide the inform ation and any agents, em ployees, and representatives from any and all liability, claim s, or dam ages that m ay directly or indirectly result from the use, disclosure, or release of any inform ation by any person or party, whether such inform ation is favorable or unfavorable to m e. I acknowledge that I have read this authorization and release, fully understand it, and voluntarily agree to its provisions. _____________________________________ Em ployees Signature Date _________________________ Print Nam e

______________EMPLOYEE: DO NOT WRITE BELOW THIS LINE!_____________ EMPLOYMENT/DEGREE VERIFICATION / REFERENCE CHECK THANK YOU FOR ASSISTING US WITH THE INFORMATION REQUESTED BELOW FOR THE ABOVE NAMED APPLICANT: COMPANY NAME:_______________________________ PH. #_________________ DATES OF EMPLOYMENT: POSITION(S) HELD: ELIGIBLE FOR REHIRE? YES______ NO______ IF NO, EXPLAIN:_______________ _____________________________________________________________________ REASON FOR WORK SEPARATION:_______________________________________ APPRAISE HIS/HER QUALITY OF WORK: ATTENDANCE / DEPENDABILITY: EXCELLENT EXCELLENT GOOD GOOD POOR POOR FROM______________ TO ______________

COMMENTS OR REMARKS:______________________________________________ VERIFICATION OF DEGREE(S): __________________________________________ SIGNATURE OF PERSON COMPLETING FORM: TITLE:_________________________________ DATE: __________________