APPLICATION FOR EMPLOYMENT. Address Number & Street City State Zip Code. Date Available Salary Desired Phone Number

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1 APPLICATION FOR EMPLOYMENT IPI is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap, genetic information, or veteran status. Name Last First Middle Date Address Number & Street City State Zip Code Position Sought Full Time Part Time Temp Date Available Salary Desired Phone Number Social Security Number Are you over 18 years old? Yes No Have you ever been convicted or pled guilty, no contest or nolo contendere, received deferred adjudication, pre-trial diversion or probation for any criminal offense (felony or misdemeanor), other than for a minor traffic violation? yes No If yes, give dates & circumstances 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.) Have you ever been terminated from employment or asked to resign by an employer? Yes No If yes, please provide company names and details: Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation? Yes No Have you ever worked for this company before? Yes No Explain Do you know anyone who works for our company? Yes No If yes, who? PROFESSIONAL LICENSE, CERTIFICATION OR MEMBERSHIP Type of License, Certification(s) Held License Expiration Date Other Professional Memberships (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.) 05/2013

2 EDUCATION: Please indicate education or training which you believe qualifies you for the position you are seeking. High School: No. of Yrs. Completed (circle one) Diploma: Yes No G.E.D.: Yes No School(s) City/State College and/or Vocational School: Number of Years Completed (circle one) School(s) City/State Major Degree(s) Earned Other Training or Degrees: School(s) City/State Course Degree or Certificate Earned EMPLOYMENT: List last employer first, including U.S. Military Service. If any employment was under a different name, indicate name May we contact your present employer? Yes No Employer Address Telephone Dates of Employment: From (mo/yr) To (mo/yr) Position Salary Supervisor FT PT Duties Reason for Leaving Employer Address Telephone Dates of Employment: From (mo/yr) To (mo/yr) Position Salary Supervisor FT PT Duties Reason for Leaving 05/2013

3 Employer Address Telephone Dates of Employment: From (mo/yr) To (mo/yr) Position Salary Supervisor FT PT Duties Reason for Leaving Employer Address Telephone Dates of Employment: From (mo/yr) To (mo/yr) Position Salary Supervisor FT PT Duties Reason for Leaving If you wish to describe additional work experience, attach the above information for each position on a separate piece of paper. Explain any gaps in work history: List software applications or special skills relative to the position for which you are applying: APPLICANT'S CERTIFICATION AND AGREEMENT I hereby certify that the facts set forth in the above employment application are true and complete to the best of my knowledge and authorize IPI to verify their accuracy and to obtain reference information on my work performance. I hereby release IPI from any/all liability of whatever kind and nature which, at any time, could result from obtaining and having an employment decision based on such information. I understand that, if employed, falsified statements of any kind or omissions of facts called for on this application shall be considered sufficient basis for dismissal. I understand that completing this form does not guarantee me status as an applicant unless I meet all stated minimum qualifications required for the position for which I am asking to be considered. I authorize IPI to supply my employment record to any prospective employer, government agency or other party with a legal and/or proper interest. I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of the Employer. However, I further understand that neither the policies, rules, regulations of employment or anything said during the interview process shall be deemed to constitute the terms of an implied employment contract. If I am employed, my compensation, hours of work and all other terms and conditions of employment are subject to change by IPI at their sole discretion. I understand that any employment offered is for an indefinite duration and at will and that either I or the Employer may terminate my employment at any time with or without notice or cause. Signature of Applicant Date: FOR HR USE ONLY: PP PI CBC FINRA DOH 05/2013

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