Download: NAR applications are available on DOH website or in our office.

Thank you for your interest in Advanced Health Care. The following information is needed for employment consideration. REQUIREMENTS: 1. Current WA state license or registration such as NAR, NAC, LPN, or RN 2. Driver s license 3. Original Social Security Card 4. Current CPR training 5. Completion of TB test (PPD) Needs to be current (within the last year) negative TB. (Or chest x- ray reading indicating negative for TB within last 10 years) 6. Evidence of completion of the 7 hour HIV/AIDS training 7. Automobile insurance (LPN s & RN s will also submit a current resume which includes dates/years of experience) APPLICATION PROCESS: 1. Fill out the application packet completely. Note that some pages are double sided. Sign and date where applicable. 2. You will need to supply us with complete names, addresses, and phone numbers for your references. No friends or family. 3. Complete the quiz and achieve a passing score of 70 percent. 4. When your application is complete and all criteria for employment have been met, we will call you to schedule an interview with one of our nursing supervisors. 5. Pending successful interview, you will be scheduled for orientation in the office. This may take up to six hours. HELPFUL RESOURCES: Washington State Department of Health 111 Israel Road SE, Tumwater, WA 98501 Town Center 2 Building www.doh.wa.gov 360-236-2397 Download: NAR applications are available on DOH website or in our office. Driving Directions to DOH: Take 1-5 South to EXIT 101 (Not Highway 101). Turn left onto Tumwater Boulevard (previously Airdustrial Way). At roundabout, take 2 nd exit.. Go to the next traffic light and turn left onto Capital Blvd. Move to the right lane, turn right on Israel Road. Town Center is on your right HIV/AIDS Training: For those needing proof of 7-hour HIV/AIDS training, classes are available in our office. Contact us to make arrangements. CPR: Call Medic 1 (Olympia) at 360-704-2780 or Hotline (Tacoma) 253-594-7979 to sign up for the next available CPR class at your local fire station. TB: Contact your doctor or any walk-in clinic. 9116 Gravelly Lake Dr. SW, Suite B1 Tacoma, WA 98499 253-475-7744 3825 Martin Way East, Suite 104 Olympia, WA 98506 360-459-7888 33801 1st Way South, Suite 255 Federal Way, WA 98033 253-874-1435

EMPLOYMENT APPLICATION Prospective employees will receive consideration without discrimination because of Race, Color, Sex, National Origin, Religion, Age, Equal Pay, and Disability (Please Print) Last Name First Name Middle Initial Social Security Number Street Address Apt/Space # Home Phone City State Zip Code Cell Phone E-mail Address How did you hear about us? AHC Employee AHC Signage Career Night Event ProCare Academy Craigslist Ad AHC Website WorkSource Job Fair School/College Career Center Other Are you available to work: 10-20 hours/wk 20-30 hours/wk 30-40 hours/wk Weekly schedule of availability for work: (Circle all available shift times): Days: Sun Mon Tue Wed Thu Fri Sat Evenings: Sun Mon Tue Wed Thu Fri Sat Nights: Sun Mon Tue Wed Thu Fri Sat Are you legally eligible for employment in the U.S.? Counties willing to work:: Pierce Thurston King Mason Lewis Grays Kitsap Transportation information: Do you own a car? Yes No Drivers License # Do you have proof of automobile insurance? Yes No Educational Background Yes No High School Diploma General Education Diploma (GED) School Name and Location of School Course of Study College Business/Trade Technical Please indicate any foreign languages that you can speak, read and/or write: Years Completed Did You Graduate? Degree or Diploma 1. Speak Fluently Read/Write Fluently Speak Fairly Read/Write Fairly 2. Speak Fluently Read/Write Fluently Speak Fairly Read/Write Fairly Have you: 1. Been convicted of a felony? Yes No 2. Been convicted of or have a criminal charge pending against you for any crime against person(s)? Yes No 3. Been convicted of any crime relating to financial exploitation of a vulnerable adult? Yes No 4. Had your name placed on a registry of child abuse in this or any other state? Yes No 5. Been found to have sexually abused or exploited or physically abused any child or adult: Yes No a. in any court action or proceedings? Yes No b. by a professional disciplinary board or the director of the dept. which issues professional licenses or certifications? Yes No 6. Been subject to an order of protection under RCW 74.34 regarding abuse or financial exploitation of a vulnerable adult? Yes No I hereby certify that the information in this application is true and complete and understand that any fraud or misrepresentation can serve as the basis for finding me unsuitable for employment. Name of Applicant Signature of Applicant Date 9116 Gravelly Lake Dr. SW, Suite B1 Tacoma, WA 98499 253-475-7744 3825 Martin Way East, Suite 104 Olympia, WA 98506 360-459-7888 33801 1st Way South, Suite 255 Federal Way, WA 98033 253-874-1435

Employment Experience/References Name of Employer Please give an accurate, complete full-time and part-time employment record. Start with your present or most recent employer. Employer Telephone Number Employer Fax Employer E-mail Address Address of Employer Name of Supervisor Job Title and brief description of your work: Employed (State Month and Year) From To Pay Rate Start Last Reason for Leaving: Name of Employer Employer Telephone Number Employer Fax Employer E-mail Address Address of Employer Name of Supervisor Job Title and brief description of your work: Employed (State Month and Year) From To Pay Rate Start Last Reason for Leaving: Name of Employer Employer Telephone Number Employer Fax Employer E-mail Address Address of Employer Name of Supervisor Job Title and brief description of your work: Employed (State Month and Year) From To Pay Rate Start Last Reason for Leaving: Professional References List the names of at least three persons NOT RELATED to you who have known you for at least one year Name Relationship Address Telephone I certify that the information given by me is true and complete to the best of my knowledge. I understand that if I am employed, the discovery that I gave false information during the application process may result in immediate dismissal. I authorize Advanced Health Care to investigate all statements contained in this application and to conduct a background check and request information about me from previous employers, educational institutions, and references. I expressly authorize my previous employers to provide information and opinions concerning my work and work habits. Further, I release Advanced Health Care and persons connected with any requests for information from all claims, liabilities, and damages for whatever reason, arising out of furnishing any information. If employed, I release Advanced Health Care from any liability for future references it may provide regarding my work history at Advanced Health Care. Due to the large number of applications that Advanced Health Care receives, I understand it cannot guarantee that my application will be considered for any or all open positions. In the event of employment, I understand that I am required to abide by all current and subsequently issued rules and regulations of Advanced Health Care and that any employment relationship with Advanced Health Care is of an at will nature. That means I can resign at any time with or without cause or notice and Advanced Health Care may terminate my employment at any time with or without cause or notice. Name of Applicant Signature of Applicant Date

Please mark (x) in the appropriate box. T Training E - Experience Please enter number of yours experience in each area Applicant Name: (Please Print) RN/LPN SKILLS AND EXPERIENCE INVENTORY LPN/RN SKILLS Alcohol Family Planning ICU Pediatric Operating Room Rehabilitation Anesthesia Geriatrics ICU Respiratory Orthopedics School Nursing Antepartum Geriatric Nurse Practice ICU Surgical Ostomy Education Substance Abuse Blood Bank Gynecology Industrial Health PACU Supervision Central Supply Hemodialysis Infection Control Pediatrics Ambulatory Surgery Ambulatory Community Healthy Home Nursing Care I.V. Team Pediatrics Inpatient Surgery Inpatient Continuing Education Home Nursing Coord. Labor and Delivery Physician s Office Urology Coronary Step Down Hospice Medicine Ambulatory Post Partum Diabetes Education ICU Burn Medicine Inpatient Private Duty Discharge Planning ICU Coronary Mental Disability Psychiatry Outpatient Ear, Nose Throat ICU General Neurology Psychiatry Inpatient Emergency, Trauma ICU Medical Newborn Nursery Public Health Enterostomal Therapy ICU Neonatal Oncology Ambulatory Radiology Family Nurse Practice ICU Neurological Oncology Inpatient Recruiting Utilization Review RN/LPN ASSESSMENT SKILLS LEADERSHIP SKILLS CLINICAL SKILLS (cont.) LIST OTHER SKILLS T E Years Exp. T E T E Circulatory Clinical/Education ECG Monitor Digestive Head Nurse Hyperalimentation Environmental Shift Charge I.V. Insertion Musculoskeletal Shift Supervisor I.V. Maintenance Neurological Team Leader NG Tube-Placement Obstetrical CLINICAL SKILLS NG Tube-Irrigation Oral T E NG Tube-Feeding Pediatric CPR Mechanical Vent. Psychiatric SVP Assessment Percussion/Post. Drainage Renal Chest Tubes POR SOAP Reproductive Ostomy Care Swan-Ganz Respiratory Dialysis Peritoneal Tracheostomy Care Social ECG 12 Lead Venipuncture LPN Med. Training To the best of my knowledge, the information given above is true and complete. I understand that any misrepresentation will be sufficient cause for my dismissal from employment with Advanced Health Care. Applicant Signature Date

Please mark (x) in the appropriate box. Training Recent Experience Training Recent Experience Training Recent Experience Training Recent Experience SKILLS AND EXPERIENCE INVENTORY HOME HEALTH AIDE SKILLS Applicant Name: (Please Print) CNA/NAC NAR/HHA Complete Bed Bath Skin Care Decubiti Use of Wheelchair Make Occupied Bed Colostomy/Ileostomy Care Use of Walker Temperature Auxiliary Tub Bath Enema Therapeutic Diet Respirators Pulse Shave Use of Bedpan Meal Planning Blood Pressure Shampoo Catheter Care Meal Preparation Observation and Reporting Mouth (oral) Care Use of Urinal Feeding Patient Charting Denture Care Nail Care Skin Care- Perineum Skin Care Bony Areas Skin Care - Feet Urine Testing (Diabetic) Turning and Positioning Antiembolism Stockings Range of Motion Transfer Techniques Home Management Intake and Output Height and Weight Temperature Oral Temperature - Rectal Isolation Techniques Safety Precautions CPR Emergency Procedures To the best of my knowledge, the information given above is true and complete. I understand that any misrepresentation will be sufficient cause for my dismissal from employment with Advanced Health Care. Applicant Signature Date

PHYSICAL REQUIREMENTS TO PERFORM THE JOB Standing / Walking: Sitting: Lifting / Carrying: Rotating of Trunk of your body: Pushing / Pulling: Bending / Stooping: Squatting / Crouching / Kneeling: Up to 7 1/2 hours or more during an eight hour shift. Only from 10 to 30 minutes per shift. Heavy lifting required: Must be able to lift at least 50 pounds multiple times without difficulty. Constantly required to reposition clients in chair or bed. Transfer of clients from several to many times during a shift. Partial lift of nonweight bearing clients with assistance of another person or use of equipment such as sliding board, Hoyer or other mechanical lift. Required frequently through shift, especially during client transfers. Frequently throughout shift. Frequently, often while lifting. Frequently during entire shift. Grasping / Handling/ Fingering (use of hands/ Fingers / wrists): Almost 100% of time during entire shift. Good manual dexterity required. Skin Exposure: Temperature: Very frequent scrubbing of hands and lower arms, as well as very frequent use of water and soap to clean clients and equipment. May be hot and humid, especially in bathing areas on hot days. I have carefully read the above and understand that the job requires vigorous effort and exertion including heavy lifting. I am capable of performing these physical requirements. Signature of Applicant/Employee Date Revised 4/30/12

CRIMINAL HISTORY INQUIRY If you apply to work for Advanced Health Care, we are required by state law (Chapter 43.43 RCW) to inquire of the Washington State Patrol if you have been convicted of any of the crimes against vulnerable adults or children listed below. If you have been convicted of any of these crimes against vulnerable adults or against children, we cannot hire you. Please ask if you need help. *Aggravated murder *Murder 1 st degree *Murder 2 nd degree *Kidnapping 1 st degree *Kidnapping 2 nd degree *Assault 1 st degree *Assault 2 nd degree *Assault 3 rd degree *Rape 1 st degree *Rape 2 nd degree *Rape 3 rd degree *Rape of a child 1 st degree *Rape of a child 2 nd degree *Rape of a child 3 rd degree *Felony indecent exposure *Prostitution *Child abuse or neglect as defined in RCW 26.44.020 *Malicious harassment *Child molestation 1 st degree *Child molestation 2 nd degree *Child molestation 3 rd degree *Patronizing a juvenile prostitute *Promoting pornography *Custodial assault *Violation of a child abuse restraining order CRIMES AGAINST PERSONS RCW 43.43.380 *Arson 1 st degree *Burglary 1 st degree *Manslaughter 1 st degree *Manslaughter 2 nd degree *Extortion 1 st degree *Extortion 2 nd degree *Indecent liberties *Incest *Vehicular homicide *Promoting prostitution 1 st degree *Communication with a minor for for immoral purposes *Unlawful imprisonment *Simple assault *Sexual exploitation of minors *Criminal mistreatment 1 st degree *Criminal mistreatment 2 nd degree *Custodial interference 1 st degree *Custodial interference 2 nd degree *Sexual misconduct w/a minor 1 st degree *Sexual misconduct w/a minor 2 nd degree *Child abandonment *Child buying or selling *Selling or distributing erotic material to a minor *Endangerment with a controlled substance CRIMES RELATING TO FINANCIAL EXPLOITATION RCW 43.43.830 *Theft 1 st degree *Theft 2 nd degree *Theft 3 rd degree *Robbery 1 st degree *Robbery 2 nd degree *Extortion 1 st degree *Extortion 2 nd degree *Extortion 3 rd degree *Forgery

OTHER *Found in a dependency action under RCW 13.34.040 to have sexually assaulted or exploited any minor or to have physically abused any minor; *Convicted of any crime against children or other person; *Convicted of crimes relating to financial exploitation if the victim was a vulnerable adult; *Found by a court in a domestic relations proceeding under Title 26 RCW to have sexually abused or exploited any minor or to have physically abused any minor; *Found in any disciplinary board final decision to have sexually or physically abused or exploited any minor or developmentally disabled person or to have abused or financially exploited and vulnerable adult; or *Found by a court in a protection proceeding under chapter74.34 RCW to have abused or financially exploited a vulnerable adult; *Convicted of crimes related to drugs as defined in RCW 43.43.830. I hereby certify under penalty of perjury that I have not been found guilty of any of the above listed crimes in a court of law or other disciplinary proceeding. Employee Applicant Signature Date

CREDENTIAL VERIFICATION I, the undersigned, authorize Advanced Health Care the permission to obtain any information regarding any past incidents of record involving elder or patient abuse or misappropriation of property and/or prescription medications properly belonging to a patient under my care. Please print below information as provided on your license, issued by Washington State Department of Health. Full Name Profession Address City Zip Code Credential Number Issue Date Expiration Date Applicant Signature Date TO BE COMPLETED BY OFFICE STAFF ONLY Verification online on by revealed the following information: DOB: LIC/REG STATUS: ISSUE DATE: COMPLAINTS: Open Closed EXP. DATE: 9116 Gravelly Lake Dr. SW, Suite B1 Tacoma, WA 98499 253-475-7744 3825 Martin Way East, Suite 104 Olympia, WA 98506 360-459-7888 33801 1st Way South, Suite 255 Federal Way, WA 98033 253-874-1435