General Information. Address NUMBER STREET CITY STATE ZIP CODE

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1 Please select the CarDon & Associates Facility you are applying to: Altenheim Arbor Trace Bell Trace Health & Living Bell Trace, Inc. Brookside Village, Inc. Brown County Health & Living CarDon Corporate Office Carmel Health & Living Countryside Manor Health & Living Greenwood Health & Living Hamilton Trace of Fishers Harbour Manor & The Lodge Lifespan Home Health Lifespan Therapy Lyons Health & Living Paoli Health & Living Rawlins House & Fall Creek Riverview Transitional Care Unit University Heights Application for Employment HEART OF CARDON, LLC is an equal opportunity employer. Applicants are considered for employment without regard to race, color, ancestry, national origin, religion, sex, age, marital status, pregnancy, and to afford equal opportunities to disabled veterans, veterans of the Vietnam era, and individuals with a disability or any other characteristic protected by Federal, State or Local law, unless such basis constitutes a bona fide occupational qualification. HEART OF CARDON, LLC will comply with its legal obligation to provide reasonable accommodation to qualified disabled applicants. PLEASE PRINT General Information Name LAST FIRST MIDDLE NUMBER STREET CITY STATE ZIP CODE How long at this address? If you have resided at this address less than one year, or if it is a temporary address, list your prior address below: Prior NUMBER STREET CITY STATE ZIP CODE Telephone ( ) Social Security Number - - If no phone, how may we contact you? Position Position(s) Desired Date available Wage Expected How were you referred to us? 1. When are you available to work? Check all that apply. Full-Time Part-Time Overtime On-Call Temporary Any Shift Day Shift Evening Shift Night Shift 2. List any restrictions on the days and hours you are available for work. 3. Are you currently on a lay-off and subject to recall? Yes No 4. Consistent attendance and punctuality are essential requirements of every job with this organization. If you are offered a job with the company, is there anything which would interfere with your regular attendance and punctuality. Yes No If yes, please explain:

2 Qualifications 1. Are you legally eligible for employment in the United States? Yes No (If offered employment, you will be required to provide documentation to verify eligibility.) 2. Are you 18 years of age or older? Yes No 3. Have you ever applied to Heart of CarDon, LLC or any of its facilities before? Yes No If yes, where? Approximate Date(s): 4. Have you ever been employed by Heart of CarDon, LLC or any of its facilities before? Yes No If yes, give dates and reason for leaving: 5. Do you have any relatives employed at Heart of CarDon, LLC or any of its facilities? Yes No If yes, please list them by name: 6. Have you been convicted of or pled guilty to a felony or misdemeanor other than a minor traffic violation? (Conviction or plea will not necessarily disqualify applicant from employment.) Yes No If yes, please explain 7. Have you ever been discharged or asked to resign from a position? Yes No If yes, please explain (In the information requested below, you need not disclose membership in professional organizations that may reveal information regarding race, color, creed, sex, religion, national origin, ancestry, age, disability, marital status, veteran status or any other protected status.) 1. Summarize special job-related skills and qualifications acquired from education, employment, volunteer work, or military service. 2. Professional License or Certificate: Type of Licenses(s) Held: State of Indiana or National License # Expiration Date: 3. Have you been a member of the armed forces of the United States? Yes No If yes, state highest rank achieved and any special skills or abilities that directly relate to the job for which you are applying: 4. Please list any personal experiences, skills, hobbies, interests or attributes which you believe enhance your qualifications for employment.

3 Employment History Starting with present or most recent job, list your employment experience below. You may include job-related military service assignments and volunteer activities that reflect your qualifications for employment. If any employment below was under a different name, please indicate other name: Employer Telephone ( ) Immediate Supervisor Dates of Employment to Salary (starting) $ (final) $ Job Title Reason for Leaving Work Performed Employer Telephone ( ) Immediate Supervisor Dates of Employment to Salary (starting) $ (final) $ Job Title Reason for Leaving Work Performed Employer Telephone ( ) Immediate Supervisor Dates of Employment to Salary (starting) $ (final) $ Job Title Reason for Leaving Work Performed If you need additional space, please continue on a separate sheet of paper and explain any gaps in work history.

4 1. Which of the positions in your Employment History did you like best and why? 2. Which of the positions listed did you like least and why? 3. May we contact the previous employers listed? Yes No If no, indicate which one(s) you do NOT wish us to contact and why: Education Type of School Name of School City and State Circle Years Completed High School Course(s) or Degree(s) College or University Business, Trade, or Technical School Graduate School References List the name, address, and telephone number of three references below who are not related to you and are not previous employers. Names of co-workers are preferred. 1. Name ( ) Telephone number Relationship 2. Name ( ) Telephone number Relationship 3. Name ( ) Telephone number Relationship

5 Applicant s Statement PLEASE INITIAL the blank by each paragraph below to indicate that you read and understood the paragraph. I certify that this application was completed by me and that all entries on it are TRUE, ACCURATE, and COMPLETE to the best of my knowledge. In the event of employment, I understand that false, misleading, or omitted information in my application may result in discharge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. In making this application for employment, I understand that an investigation may be made and information may be obtained through interviews with the personal references and past employers listed. This inquiry may include information as to my character, general reputation, and personal characteristics, as well as information about my work performance and workplace conduct. I consent to this investigation and to the consideration of any statements of references of former employers that are given in response to this inquiry. I hereby release all parties, including but not limited to HEART OF CARDON, LLC, personal references, and previous employers, from any and all liability for any injury or damage that may result from their furnishing information to HEART OF CARDON, LLC concerning me or any action HEART OF CARDON, LLC takes on the basis of such information. I understand that part of the application/hiring process may include a pre-employment drug test. If I choose not to submit to testing, or the result is positive, I understand that I will not be considered for employment. In the event of employment, I agree to submit to a medical examination, including drug testing, if required, and understand that any offer of employment is contingent upon the results of that examination. I hereby authorize any doctor, hospital, clinic, laboratory, or other medical facility to furnish any medical information with reference to me as may be necessary. I understand that this consent to release of medical records is revocable, in writing, by me at any time. I understand that this application is not, and is not intended to be, a contract of employment and that any resulting employment relationship is for no fixed period of time and is terminable at any time and for any reason by HEART OF CARDON, LLC or by me. I further understand that statements which may be contained in policies, practices, handbooks, or other HEART OF CARDON, LLC material do not create any guarantee of employment; and that HEART OF CARDON, LLC has the right to modify, amend, or terminate policies, practices, benefits plans, or other programs within the limits and requirements imposed by law. I understand that no representative of HEART OF CARDON, LLC other than an officer, has the authority to enter into any agreement for any specific period of time or to make any agreement contrary to the foregoing, and that any such agreement must be in writing to be binding on HEART OF CARDON, LLC. I have been given the opportunity to review the job description for the position for which I am applying. I believe I can perform the essential functions of the job without accommodations. If I feel I will require accommodations I will discuss with the hiring manager. Date Signature of Applicant THIS APPLICATION WILL REMAIN ACTIVE FOR THREE MONTHS. AFTER THAT TIME, YOU WOULD NEED TO FILL OUT A NEW APPLICATION FOR CONSIDERATION OF EMPLOYMENT.

6 The Heart of CarDon Image Pre-Application Information Thank you for considering employment with Heart of CarDon. In order for us to be successful, we depend on working with people who have shared values for meeting the needs of those who require our care. Our primary goal is to make each CarDon & Associates location the facility of choice for the community we serve. In order to accomplish this goal, we have found that the following expectations are important and necessary for everyone who works with us. Please read them carefully. PRIDE: Taking Care of People. Be a Difference Maker. Making a Difference. These are the words that inspire us. It is important to remember that each person has value. You will treat each resident as a valuable and respected person of the community. You will be encouraged to help us make our facilities places where we all have a great deal of pride working. Many responsibilities of your job will result in love, care, happiness and compassion for our residents, their families and you! By greeting others with a smile and following the steps that help to make a positive image, you will help us achieve another of our goals in providing peace of mind to all who live and work here. RESPECT: You will have a feeling of personal pride when you treat residents, families, visitors, and co-workers with respect and dignity. This means treating others as they would like to be treated at all times. It is necessary to treat our facilities and all resident property with respect also. Our employees must use courtesy, good manners and patience at all times. BEING A GOOD CITIZEN: Being a good citizen includes not using foul or suggestive language at any time. You need to immediately report to your supervisor any possible instances of verbal or physical abuse of a resident or staff member, and to bring to your supervisor s attention any missing items belonging to a resident or staff member. In cases where we determine upon our investigation that incidents are reportable to regulatory or law enforcement agencies, we will report them promptly and be as aggressive as possible in implementing corrective action. By doing such, we will be providing safety, security and peace of mind to all of our customers CONFIDENTIALITY: Resident privacy is extremely important. By agreeing to the Heart of CarDon Image, you agree not to discuss any matters outside the facility involving our residents. This includes the delivery of services within the facility. Failure to uphold confidentiality may result in your losing your employment with us. DRUG-FREE WORKPLACE POLICY: Our facilities are committed to providing a safe and productive work environment for the benefit of our residents and employees. To that end, we take a very aggressive and proactive stance against drug and alcohol abuse in our facility. All of our employees must refrain from the use or possession of alcohol or drugs while on our premises and must not report to work under the influence of alcohol or drugs. Failure to adhere to our policy will be cause for non-hire or termination of employment. PERSONAL STANDARDS: It is extremely important that you report to work on time as scheduled each day clean and well groomed. Each department has its own standards of dress or dress code that will be explained to you and enforced. Following are items that are common to every department: Uniforms and shoes are to be clean and in good professional condition. Hair is to be worn neatly and of acceptable professional lengths and colors for both men and women. Moustaches and beards will be neatly trimmed. Fingernails need to be clean and neatly trimmed at all times. Deodorant is to be used daily. Cologne or other fragrances, if used, must be used in moderation and lightly applied.

7 Jewelry is acceptable in moderation. Earrings are acceptable for women and men but no more than three per ear. For the comfort of our residents and for your personal safety, please refrain from wearing any visible piercing other than those mentioned above. Staff Identification: You will wear a nametag as your identification for staff, residents, families and visitors. Tattoos and other markings of the skin should be hidden from the view of our residents. We are a tobacco-free facility. An outdoor smoking area may be provided for those who choose to smoke on their regularly scheduled breaks. Please keep in mind that the smoking area is subject to elements of weather. PROMPTNESS: It is your responsibility to arrive at work on time and to work the hours scheduled for you. One of the largest and most costly problems in health care today is the tardiness and absenteeism of employees, but if you understand the importance of being prompt, you can help be a part of the solution to this problem. Weekends and holidays are set on a rotation basis to help be fair to all. Please keep in mind that our services are provided twenty-four hours a day, seven days a week, so some employees will be working specific weekend and holiday shifts. OUR WORK: Working in a health care facility may be hard, demanding and stressful. Some jobs require heavy lifting, cleaning of soiled linens and residents, working under time constraints, and dealing with matters of death and dying. At the same time, the work can be very rewarding and you will find a great deal of personal and spiritual satisfaction. There is the possibility of establishing friendships with those you work with and there are opportunities to develop your personal career path. If you agree that you will be able to meet the standards that have been set, please complete the employment application. If you believe that you cannot make this commitment, then we thank you for considering us as a possible place of employment. Please know that as a staff member, you will be very important to us and we encourage your input on making us better. Our success depends on each of our abilities to meet the requirements described in the preapplication expectations. We are very proud of our heritage of being able to provide a quality service. We believe it is important to let you know up front what some of our expectations are. You will need to know them and accept them to be successful here. Working with us can make a difference in your life and someone else s. Thank you again for considering us. Sincerely, The Staff of Heart of CarDon Signature of Applicant Date

8 EQUAL EMPLOYMENT OPPORTUNITY DATA FORM Heart of CarDon (CarDon & Associates, Inc.) To All Employees: To enable us to meet government reporting requirements, Heart of CarDon requests that you complete this personal data information form. Information collected will be used solely for government reporting purposes and will be kept separate from your personnel file. Any information that you choose to provide will not be considered by Heart of CarDon for any employment purposes and will be treated as confidential. Your voluntary cooperation is appreciated. Name: Last First MI I decline to identify my ethnic/racial identity and/or my gender. I understand that visual identification of my gender, race or ethnicity will be made by company personnel for purposes of government reporting. GENDER: Male Female ETHNICITY: Are you Hispanic or Latino? (A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin) Yes No RACE: Please check the box(es) that most closely fits your racial identity: White A person having origins in any of the original peoples of Europe, North Africa, or the Middle East. Black or African American A person having origins in any of the black racial groups of Africa. Native Hawaiian or other Pacific Islander A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands Asian A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including (for example) Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. American Indian or Alaska Native A person having origins in any of the original peoples of North and South America (including Central America) and who maintain cultural identification through tribal affiliation or community attachment. Two or More Races a person who identifies with more than one of the above races.