Employment Application

Application Note:

This application is intended for use in evaluating your qualifications for employment. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment, terminating employment. All qualified individuals applicants will receive consideration without discrimination based on sex, marital status, race, color, age, greed, national origin, sexual orientation, military service membership, ancestry, religion, height, weight, use of guide or support animal because of blindness, deafness or physical handicap or presence of disabilities. A conviction will not necessarily bar an application from employment. Additional testing or job-related skills and for the presence of drugs in your body maybe required prior to employment. After an offer of employment, and prior to reporting to work, you may be required to submit to a medical review. Depending on company policy and the needs of the job, you will be required to complete a medical history form and may be required to be examined by a medical professional designated by the company.

PLEASE NOTE: Your application will not be considered unless every question in this section is answered. Since we will make every effort to contact previous employers, the correct telephone numbers of past employers are critical. Ask for phone book or call information if necessary. FOR EMOLOYERS OUTSIDE THE U.S. A CURRENT FAX NUMBER IS MANDATORY. Please list the names of your present of previous employers in chronological order with present or last employer listed first. Be sure to account for ALL periods of time including military service and any period of unemployment. If self-employed, give firm name and supply business references. [Add additional page if necessary]

THIS APPLICATION WILL BE CONSIDERED ACTIVE FOR A MAXIMUM OF THIRTY (30) DAYS, IF YOU WISH TO BE CONSIDERED FOR EMPLOYMENT AFTER THAT TIME, YOU MUST REAPPLY.

I certify that I have read and understand the applicant note on page on of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omission or misinterpretation of facts called for in this application, whether on this document or not, may result in rejection of my application or discharge at any time during my employment. If company requires, I am willing to submit drug testing to detect the use of illegal drugs prior to or during employment.

I CERTIFY THAT ALL INFORMATION THAT I HAVE PROVIDED ON THIS APPLICATION IS TRUE, ACCURATE, AND COMPLETE.

I have the right to make a request to IntelliCorp Records, Inc. or Sentrylink, Inc. upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which “record company” has previously furnished within the two year period preceding my request. I certify that all elements of the personal data I have provided are true, accurate and complete. I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.

As a Company dedicated to providing quality services, QURA HEALTHCARE, INC. has adopted a Drug and Alcohol Policy applicable to all of its employees. Employment of newly hired employees with the Company is contingent on passing an examination, which includes testing for narcotics, hallucinogenic drugs, marijuana or other controlled substances. I agree and consent to taking any blood, “breathalyzer”, urinalysis or other diagnostic tests as requested by the Company as part of an employment examination or otherwise and authorize release of any test results to the Company. I understand the following are considered a voluntary withdrawal of my application for employment that precludes further considerations for employment, for at least six (6) months and only after completing a medically supervised substance abuse program: A)Failure to consent to testing; B)Discovery of any evidence which, in the opinion of the company or testing laboratory, indicates thatthe blood or urine sample has been altered, substituted, or tampered with in any way; C)Failure to report for testing by end of business day as indicated on the collection guideline form. If hired by the Company, I hereby give my consent to any drug or alcohol testing as may be required by the Company, except where prohibited by law, and authorize release of any such test results to the Company.

Please Read Carefully Before Signing the Authorization DISCLOSURE In considering you for employment and, if you are employed, in considering you for subsequent promotion, assignment, reassignment, retention, yearly background as required by State health Department or Medicare, or discipline, QURA HEALTHCARE, INC. (“the Company”) may request any rely upon one or more consumer reports or investigative consumer reports about you that we obtain from a consumer reporting agency, such as IntelliCorp Records, Inc. or Sentrylink, Inc. IntelliCorp Records, Inc. can be contacted by mail at 3000 Auburn Dr, Suite 410; Beachwood, OH 44122; or phone 1-888-946-8355; or website: www.intellicorp.net Sentrylink, Inc. can be contacted by mail at 7500 Grenway Center Dr, Suite 1040; Greenbelt, MD 20770 or phone 1-301-486-0862; or website: www.sentrylink.com For explanation purposes: • a “consumer report” us a written, oral or other communication of any information by a consumerreporting agency bearing on your credit worthiness, credit standing, credit capacity, character,general reputation, personal characteristics, or mode of living which is used or expected to be usedor collected in whole or in part for the purpose of serving as a factor in making an employment-related decision about you. Such information may include, for example, credit information, criminalhistory reports, or driving records; • an “investigative consumer report” is a consumer report in which information on your character,general reputation, personal characteristics, or mode of living is obtained through personalinterviews with your prior employers, neighbors, friends, or associates, or with others who mayhave knowledge concerning any such items of information. In the event an investigative consumerreport is requested about you, you are entitled to additional disclosures regarding the nature andscope of the investigation requested, as well as a written summary of your rights under the FairCredit Reporting Act (“ FCRA”). Under the FCRA, before the Company can obtain a consumer report or investigative consumer report about you for employment purposes, we must have your written authorization. Before we take adverse action on the basis, in whole or in part, of information in that report, you will be provided a copy of that report, the name, address and telephone number reporting agency, and a summary of your rights under the FCRA.

I have read and understand the foregoing Disclosure, and authorize QURA HEALTHCARE, INC. to obtain and rely upon consumer reports or investigative consumer reports in considering me for employment and, if I am employed, in considering me for subsequent promotion, assignment, reassignment, retention, or discipline. By my Signature below, I authorize the Company to obtain any such reports and to share the information received with any person involved in the employment decision about me.

(This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference Section of your application.) I also agree that this Disclosure and Authorization in original, faxed, photocopied, or electronic (including electronically signed) form will be valid for any consumer reports or investigative consumer reports that may be requested about me by or on behalf of the Company.

Under California Civil Code §§ 1786.16(a)(2) and 1786.22, the following additional disclosure should be provided before procuring a consumer report: We will be obtaining a consumer report from IntelliCorp Records, Inc. SentryLink, Inc. You have the right to request from those agency’s, upon proper identification, the nature and substance of all information in its files on you, including the sources of information, and the recipients of any reports on you, which the agency has previously furnished within the three-year period preceding your request. You may view the file maintained on you by the agency during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services. Upon making a writer request, you may receive a summary of your report via telephone.