EMPLOYMENT APPLICATION

SBHIS is an equal opportunity employer and does not discriminate against any applicant or employee because of race, color, religion, sex, national origin, disability, age, or military or veteran status in accordance with federal law. In addition, SBHIS complies with applicable state and local laws governing non-discrimination in employment in every jurisdiction in which it maintains facilities. SBHIS also provides reasonable accommodation to qualified individuals with disabilities in accordance with applicable laws.

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PLEASE PLACE A CHECK BY YOUR RESPONSE OR PROVIDE THE APPROPRIATE INFORMATION

PLEASE CHECK THE FOLLOWING

Federal law requires that employers hire only individuals who are authorized to be lawfully employed in the United States. In compliance with these laws, SBHIS will verify the status of every individual offered employment with the Company. In this connection, all offers of employment are subject to verification of the applicant’s identity and employment authorization, and it will be necessary for you to submit such documents as are required by law to verify your identification and employment authorization

PLEASE LIST YOUR WORK EXPERIENCE BELOW (MOST RECENT JOB FIRST)

Massachusetts applicants may include any verified work performed on a volunteer basis.

EDUCATION

Name and Address of School

PROFESSIONAL LICENSES

REFERENCES: Please list three professional references

PLEASE READ CAREFULLY BEFORE SIGNING APPLICATION

I have submitted the attached form to the company for the purpose of obtaining employment. I acknowledge that the use of this form, and my filling it out, does not indicate that any positions are open, nor does it obligate the company to further process my application. My signature below attests to the fact that the information that I have provided on my application, resume, given verbally, or provided in any other materials, is true and complete to the best of my knowledge and also constitutes authority to verify any and all information submitted on this application. I understand that any misrepresentation or omission of any fact in my application, resume or any other materials, or during any interviews, can be justification for refusal of employment, or, if employed, termination from the Company’s employ. I also affirm that I have not signed any kind of restrictive document creating any obligation to any former employer that would restrict my acceptance of employment with the Company in the position I am seeking. I understand that this application is not an employment contract for any specific length of time between the Company and me, and that in the event I am hired, my employment will be “at will” and either the Company or I can terminate my employment with or without cause and with or without notice at any time. Nothing contained in any handbook, manual, policy and the like, distributed by the Company to its employees is intended to or can create an employment contract, an offer of employment or any obligation on the Company’s part. The Company may, at its sole discretion, hold in abeyance or revoke, amend or modify, abridge or change any benefit, policy practice, condition or process affecting its employees. References: I hereby authorize the company and its agents to make such investigations and inquiries into my employment and educational history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, and other persons from all liability in responding to inquires connected with my application and I specifically authorize the release of information by any schools, businesses, individuals, services or other entities listed by me in this form. Furthermore, I authorize the company and its agents to release any reference information to clients who request such information for purposes of evaluating my credentials and qualifications. Temporary/Contract Employment: If employed as a temporary or contract employee, I understand that I may be an employee of the company and not of any client. If employed, I further understand that my employment is not guaranteed for any specific time and may be terminated at any time for any reason. I further understand that a contract will exist between the company and each client to whom I may be assigned which will require the client to pay a fee to the company in the event that I accept direct employment with the client, I agree to notify the company immediately should I be offered direct employment by a client (or by referral of the client to any subsidiary or affiliated company), either for a permanent, temporary (including assignments through another agency), or consulting positions during my assignment or after my assignment has ended.

For Massachusetts Applicants Only

IT IS UNLAWFUL IN MASSACHUSETTS TO REQUIRE OR ADMINISTER A LIE DETECTOR TEST AS A CONDITION OF EMPLOYMENT OR CONTINUED EMPLOYMENT. AN EMPLOYER WHO VIOLATES THIS LAW SHALL BE SUBJECT TO CRIMINAL PENALTIES AND CIVIL LIABILITY.

For Maryland Applicants Only

POLYGRAPH NOTIFICATION AND ACKNOWLEDGMENT: UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. ANY EMPLOYER WHO VIOLATES THIS PROVISION IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.

For California Applicants Only

I acknowledge that in connection with my application for employment or subsequentemployment, [Employer Name] may collect, assemble, evaluate, compile, report, transmit, transfer or communicate information on my character, general reputation, personal characteristics or mode of living which are matters of public record without using a third party investigative consumer reporting agency. Matters of public record are defined as records documenting an arrest, indictment, conviction, civil judicial action, tax lien, or outstanding judgment. I understand that such public record information generally must be disclosed to me within seven days of the date the information is received by my prospective employer, regardless of whether it is received orally or in writing. I understand that I may waive my right to receive such information.