Please complete all fields and submit the completed application and discloser forms to be considered for employment.

Please list three personal or professional references.

You also certify your understanding that Texas is an “at-will” state. If you are hired, as an at-will employee, you will be free to terminate your employment with the Company at any time, with or without cause. Likewise, the Company will have the right to reassign you, to change your compensation or benefits, or to terminate your employment at any time, with or without cause.

The Agency is an equal employment opportunity employer dedicated to an employment policy of nondiscrimination in employment on any basis including race, color, age, sex, religion, disability or national origin.

BLUEBONNET HEALTH SERVICES (“THE COMPANY”) MAY OBTAIN INFORMATION ABOUT YOU FOR EMPLOYMENT PURPOSES FROM A THIRD PARTY CONSUMER REPORTING AGENCY. THUS, YOU MAY BE THE SUBJECT OF A “CONSUMER REPORT” AND/OR AN “INVESTIGATIVE CONSUMER REPORT” WHICH MAY INCLUDE INFORMATION ABOUT YOUR CHARACTER, GENERAL REPUTATION, PERSONAL CHARACTERISTICS, AND/OR MODE OF LIVING, AND WHICH CAN INVOLVE PERSONAL INTERVIEWS WITH SOURCES SUCH AS YOUR NEIGHBORS, FRIENDS, OR ASSOCIATES. THESE REPORTS MAY CONTAIN INFORMATION REGARDING YOUR CREDIT HISTORY, CRIMINAL HISTORY, SOCIAL SECURITY VERIFICATION, MOTOR VEHICLE RECORDS (“DRIVING RECORDS”), VERIFICATION OF YOUR EDUCATION OR EMPLOYMENT HISTORY, OR OTHER BACKGROUND CHECKS. CREDIT HISTORY WILL ONLY BE REQUESTED WHERE SUCH INFORMATION IS RELATED TO THE DUTIES AND RESPONSIBILITIES OF THE POSITION FOR WHICH YOU ARE APPLYING. YOU HAVE THE RIGHT, UPON WRITTEN REQUEST MADE WITHIN A REASONABLE TIME AFTER RECEIPT OF THIS NOTICE, TO REQUEST DISCLOSURE OF THE NATURE AND SCOPE OF ANY INVESTIGATIVE CONSUMER REPORT AND A COPY OF ANY REPORT ABOUT YOU. PLEASE BE ADVISED THAT THE NATURE AND SCOPE OF THE MOST COMMON FORM OF INVESTIGATIVE CONSUMER REPORT OBTAINED WITH REGARD TO APPLICANTS FOR EMPLOYMENT IS AN INVESTIGATION INTO YOUR EDUCATION AND/OR EMPLOYMENT HISTORY CONDUCTED BY LEXISNEXIS SCREENING SOLUTIONS INC, P.O. BOX 105108, ATLANTA, GA 30348-5108,1-800-845-6004, WWW.LEXIS.COM/RISK/SOLUTIONS. THE SCOPE OF THIS NOTICE AND AUTHORIZATION IS ALL-ENCOMPASSING, HOWEVER, ALLOWING THE COMPANY TO OBTAIN FROM ANY OUTSIDE ORGANIZATION ALL MANNER OF CONSUMER REPORTS AND INVESTIGATIVE CONSUMER REPORTS NOW AND THROUGHOUT THE COURSE OF YOUR EMPLOYMENT TO THE EXTENT PERMITTED BY LAW. AS A RESULT, YOU SHOULD CAREFULLY CONSIDER WHETHER TO EXERCISE YOUR RIGHT TO REQUEST DISCLOSURE OF THE NATURE AND SCOPE OF ANY INVESTIGATIVE CONSUMER REPORT. BLUEBONNET HEALTH SERVICES MAINTAINS A DRUG FREE WORK ENVIRONMENT AND EMPLOYEE CANDIDATES MUST PASS A DRUG SCREENING. BY SIGNING BELOW YOU ALSO CONSENT TO A DRUG SCREENING.

P O Box 105108 Atlanta, GA 30348-5108 1-800-845-6004 FCRA Summary You must be told if information in your file has been used against you. Anyone who uses information from a CRA to take action against you - such as denying an application for credit, insurance, or employment must tell you, and give you the name, address, and phone number of the CRA that provided the consumer report. You can find out what is in your file. At your request, a CRA must give you the information in your file, and a list of everyone who has requested it recently. There is no charge for the report if a person has taken action against you because of information supplied by the CRA, if you request within 60 days of receiving notice of the action. You also are entitled to one free report every twelve months upon request if you certify that (1) you are unemployed and plan to seek employment within 60 days, (2) you are on welfare, or (3) your report is inaccurate due to fraud. Otherwise, a CRA may charge you up to eight dollars. You can dispute inaccurate information with the CRA. If you tell a CRA that your file contains inaccurate information, the CRA must investigate the items (usually within 30 days) by presenting to its information source all relevant evidence you submit, unless your dispute is frivolous. The source must review your evidence and report its finding to the CRA. (The source also advise national CRAs – to which it has provided the data – of any error.) The CRA must give you a written report of the investigation, and a copy of your report if the investigation results in any change. If the CRA's investigation does not resolve the dispute, you may add a brief statement to your file. The CRA must normally include a summary of your statement in future reports. If an item is deleted or a dispute statement is filed, you may ask that anyone who has recently received your report be notified of the change. Inaccurate information must be corrected or deleted. A CRA must remove or correct inaccurate or unverified information from its files, usually within 30 days after you dispute it. However, the CRA is not required to remove accurate data from your file unless it is outdated (as described below) or cannot be verified. If your dispute results in any change to your report, the CRA cannot reinsert into your file a disputed item unless the information source verifies its accuracy and completeness. In addition, the CRA must give you a written notice telling you it has reinserted the item. The notice must include the name, address, and phone number of the information source. You can dispute inaccurate items with the source of the information. If you tell anyone – such as a creditor who reports to a CRA – that you dispute an item, they may not then report the information to a CRA without including a report the information if it is, in fact, an error. Outdated information may not be reported. In most cases, a CRA may not report negative information that is more than seven years old: ten years for bankruptcies. Access to your file is limited. A CRA may provide information about you only to people with a need recognized by the FCRA – usually to consider an application with a creditor, insurer, landlord, or other business. Signature required page 3 and 5 Revised 1/1/13 Page 5 of 5 Your consent is required for reports that are provided to employers, or reports that contain medical information. A CRA may not give out information about you to your employer, or prospective employer, without your written consent. A CRA may not report medical information about you to creditors, insurers, and employers without your permission. You may choose to exclude your name from CRA lists unsolicited credit insurance offers. Creditors and insurers may use file information as the basis for sending you unsolicited offers of credit insurance. Such offers must include a toll-free phone number for you to call if you want your name and address removed from future lists. If you call, you must be kept off the lists for two years. If you request, complete, and return the CRA form provided for this purpose, you must be taken off the lists indefinitely. You may seek damages from violators. If a CRA, a user or (in some cases) a provider if CRA data, violates the FCRA, you may sue them in state or federal court. ACKNOWLEDGMENT AND AUTHORIZATION I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company at any time after receipt of this authorization and throughout my employment, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by LexisNexis Screening Solutions Inc., P.O. Box 105108, Atlanta, GA 30348-5108,1-800-845-6004, www.lexis.com/risk/solutions, another outside organization acting on behalf of the Company, and/or the Company itself. LexisNexis® Screening Solutions Privacy Policy: privacypolicy.lexisnexis.com/screen.html. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.