On Line Employment Application

1. * Have you ever been discharged or asked to resign from a job? Yes No
2. * Do you possess a valid driver's license? Yes No      If yes, please put state of issue and number:
3. * Has your driver's license ever been suspended or revoked? Yes No

4. * To your knowledge, are you listed on CMS's "List of Excluded Individuals/Entities" as someone who is excluded from participation in Medicare/Medicaid or any other federally funded health care programs? Yes No
   Family Choice of New York will not hire or continue employment of those individuals who are in the database and are currently excluded from Medicare program participation.
5. * Can you meet the attendance requirements of the job? Yes No
6. * Have you ever been convicted of a felony? Yes No    If yes, please explain
   If yes, please explain the conviction. (A conviction will not necessarily disqualify you from employment.) Exclude convictions for marijuana-related offenses for personal use that are more than two years old; convictions that have been sealed, expunged, or legally eradicated; and misdemeanor convictions for which probation was completed and the case was judicially dismissed pursuant to the Penal Code Section 1203.4. You may also exclude minor traffic violations. Drunk or reckless driving is not considered to be minor.
   
7. Have you ever had any criminal conviction relating to:
   1. * any federal health care program including Medicare and Medicaid? Yes No
   2. * patient neglect or abuse? Yes No
   3. * health care fraud? Yes No
   4. * use of controlled substances? Yes No
   5. * fraud, theft, embezzlement? Yes No
   6. * breach of fiduciary responsibility or other financial misconduct? Yes No
   7. * obstruction to a health care investigation? Yes No
   8. * any criminal offense involving violence or assault? Yes No
8. * Have you ever had a license to provide health care revoked, limited, modified, suspended? Yes No
9. It is the policy of Family Choice of New York to check an employee's Department of Motor Vehicle's driving record upon hire and on an annual basis. An individual will not be eligible for hire or continued employment if they:

• Have had more then three (3) moving violations or more than one chargeable accident in the past thirty-six (36) months.
• Have had a major conviction (driving under the invluence of alcohol or drugs) within the past seven (7) years.

PLEASE READ:
The facts set forth in my application for employment are true and complete. I understand that if employed, false statements or omissions on this application will usually result in termination of employment. I understand that an offer of employment is contingent upon satisfactory proof of lawful employment status as set forth in the Immigration Reform and Control Act. Permission is hereby given to the Company to investigate previous employment, educational background and references. I release the Company and former employers from any liability resulting from any lawful information provided which may result in withdrawal of an employment offer or termination. I also understand that I am not eligible for employment with Family Choice of New York if I am at any time, subject to exclusion from participating in any federally funded health care program.

I understand that the Company has a policy prohibiting conflicts of interest or improper use of proprietary information which prohibits any release or use of Company property that would interfere with the business interests or operations of the Company. I understand that employment with the Company is at will and may be terminated at any time by either the Company or myself with or without cause.