MIRACLE VILLAGE, INC Birmingham Street Tallahassee, F City State Zip. City

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1 MRACLE VLLAGE, NC Birmingham Street Tallahassee, F PERSONAL NFORMATON Social Security Number Last Name First Name Middle Name / Present Address Street City State Zip Street City State Zip Home Telephone Number Work Telephone Number of Birth f related to anyone in our establishment, state name and department: _ ATe You Dual Employed? Yes No, f Yes, Where? _ EMPLOYMENT DESRED Position you can start Salary Desired _ Are You Employed Now? f so, May we nquire of Your Present Employer? _ Have You Applied To This Company Before? f So, When? _ Education Name & Location Years Attended Graduated Subject Studied Of School Grammar School High School i J College Trade Business Correspondence / School Subjects of Special Study or Research Work _

2 \}/h2it Foreign Language Do You Speak Fluently? Read? Write? _ U. S. Military Services _ Present Membership in National Guard of Reserves _ FOlmer Employers (List the last foul' employers, starting with the present or last on first.) Name and Address Salary Position Reason for leaving Month and Year of Employer References: Give the name of three persons not related to you, whom you have know for at least one year. Name Address Business Years Acquainted authorize investigation of all statement contained in this application. understand that misrepresentation or omission of facts is cause for dismissal. Signature PERSONNEL USE ONLY nterviewed by: : _ Appearance: Skills Related to Job: _ Attitude: Other Assets: _ Remarks: _ Hired: For What Department Salary/Wages _ Position: to Report to Work: _ Approved by: nterviewer: _ Supervisor: Manager:

3 MRACLE VLLAGE, NC Birmingham Street Tallahassee, FL NOTCE: TO ALL EMPLOYEE ANT) JOB APPLCANTS DRUG FREE WORKPLACE t is the policy of Miracle Village, nc. to maintain a Drug Free Workplace in accordance with Section 440, Florida Statutes, Drug - Free Workplaces. t is a condition of employment for employees to refrain from the inappropriate use of drugs. Miracle Village, nc. is committed to maintaining a safe work environment and to fostering the health and well being of our employees. Our commitment is jeopardized when any company employee illegally uses drugs on the Job, comes to work under the influence, possesses, distributes, or sells drugs in the workplaces. Miracle Village, nc. has therefore, decided to implement a Drug Free Workplace Program. Drug abuse is discouraged by Miracle Village. We perform drug testing. f there is a positive confirmed test, you will be denied employment with this company. Employees who choose to engage in drug abuse face the risk of unemployment and the forfeiture of workers' compensation benefits. Refusal to submit to a drug testing will result to ineligibility for employment or in automatic termination. f an employee is injured at work and refuses to submit to a test for drugs, the employee may also forfeit hislher eligibility for medical and indemnity benefits. Use of the word 'Drug" at lvllracle VLLAGE, Alcohol A distilled spirit a Wille a malt beverage; An amphetamine a opiate a hallucinogen A synthetic narcotic a barbiturate a benzodiazepine Or a metabolite of any ofthe substances. Methaqualone, a designer drug, cocaine NC. means: an intoxicating, liquor a cannabinoid phencyclidine (PCP) We may test an individual for any or all of these substances through job applicant, reasonable suspicion, followup drug testing, or post accident drug testing. vuracle VLLAGE, NC. will pay for the cost of all drug tests, initial and confirmation, which we require of our employees and job applicants. Certain drugs may alter 01' affect a drug test. Employees and job applicants have the right to confidentially.l- h f... " f,r 1" R. r-v or- (l'..ro' f s: repor d ft. L t e use 0 prescription or non - prescnpnon mugs to a lvlemcal xeview UlCel',.1vi <.. ) oerorc an 3.1el being tested. You also have the right to consult with the MRO or the Laboratory for technical information regarding prescription 01' non-prescription medication. The name of the MRO is DL Len Goff and Dr. Dung Nguyell1vLD. at Patients F'irst'located at 505 Apple Yard Dr, Tallahassee, Florida Phone l... Jumber (850) , ''Z{GU will be given a form, which lists the 110s1C0!11lTOl medications that may alter or affect a drug test. T"J1Cform list.s the. drugs by brand name or common name, as \~rcn as by chemica} name. /~.'" list of SlCh D1t'.d1c&tl011Sdeveloped by the Florida Agency for Health Care Administration is attached to this Notice!l11d can be found in [he personnel office. An employee or job applicant vv110 receives a positive coll!11111eadrug test result lllay contest 01 explain the result to the vfrj). within five (5) working days after receiving written notification of the test results. f an

4 employee or job applicant's explanation or challenge is unsatisfactory to the MRO, the MRO shall report a positive test result back to the individual. The person may contest the drug test result according to the release adopted by the Florida Department of Labor and Employment Security. f an employee or job applicant undertakes a challenge to the results of a test, it is his/her responsibility to notify the laboratory of any administrative or civil actions. This notifies the laboratory to retain the sample until the case is settled. Within this community there are employee assistance programs and alcohol and drug rehabilitation programs. We have compiled a current resource file of local providers of employee-assistance. These organizations are designed to assist someone faced with personal or behavioral problems. The names, addresses, and telephone numbers of these Agencies are located in the personnel office for review. All information, interviews, reports statement memoranda, and drug test results, written 01' otherwise, received by MRACLE VLLAGE, NC. through a drug testing company are confidential communications. A written consent form signed by the employee or job applicant shall only permit release of such information under any other circumstances, An exception to this would be if a hearing officer or a court of competent jurisdiction according to an appeal compels such release or unless deemed appropriate by a professional or occupational licensing board in a related disciplinary proceeding. This notice and policy will be given to all employees and job applicants. A written notice of drug testing is alsoincluded on all company job vacancy announcements. Drug testing for all job applicants will begin immediately. All active employees may be required to take a drug test as set forth in this notice 60 days from today's date September 8, A copy of the complete MRACLE VLLAGE, NC. Drug Free Workplace Program has been permanently posted on the east side bulletin board and at the employee's time clock room. Employee/Job Applicant Signature: _ :

5 ArrESTATON OF RESDENCY The following information is provided to identify the individual attesting to the residency requirement for background screening pursuant to s , F.S. Name: Address: City: State: Zip: _ Social Security Number: _ of Birth: Sex: Race: _,, do hereby attest under penalty of perjury that have physically resided in the state of Florida for the previous 5 years and do hereby meet the residency requirement set forth as a condition of background screening pursuant to s , F.S. Signature of Affiant -OR-,, do hereby attest under penalty of perjury that have not physically resided in the state of Florida for the previous 5 years and do therefore, do not meet the residency requirement set forth as a condition of background screening and may be subject to Level two screening requirements. Signature of Affiant