ESPERANZA HEALTH SYSTEMS, LTD. D/B/A LA HACIENDA TREATMENT CENTER ARBITRATION AGREEMENT

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1 ESPERANZA HEALTH SYSTEMS, LTD. D/B/A LA HACIENDA TREATMENT CENTER ARBITRATION AGREEMENT PLEASE READ AND SIGN THIS PAGE BEFORE COMPLETING THE APPLICATION PACKET Esperanza Health Systems, Ltd. D/B/A/ La Hacienda Treatment Center and its related entitities ( La Hacienda ) has adopted binding arbitration as a process to resolve all employment related disputes. This includes those disputes involving applicants. Before La Hacienda will consider anyone as an applicant, he/she must agree to submit to binding arbitration for any legal claims which he/she chooses to bring against La Hacienda. Any claims filed regarding the application process will be governed by the provisions of La Hacienda s Open Door Policy for Dispute Resolution. A copy is available and will be provided upon request. Applicant s Name Date Printed Name

2 EMPLOYMENT APPLICANT S RELEASE OF EMPLOYMENT RECORDS I,, hereby authorize a representative of Esperanza Health Systems, Ltd., d/b/a La Hacienda to investigate all facts contained in my application for employment with said facility, and authorize the release of any and all information by my present (if indicated on application that this would not pose any difficulty) and past employers, wherever located, which may be required for a reference check. I further authorize all of my previous employers and current employer to give any and all information concerning my employment and any other pertinent information which said employers may have, personal or otherwise, and I release all parties from all liabilities for any damages which my result from the furnishing of said information. A copy of this release shall be as valid as the original. Dated: Applicant Signature Witness Signature Printed Name of Applicant Printed Name of Witness

3 AN EQUAL OPPORTUNITY EMPLOYER APPLICATION FOR EMPLOYMENT PLEASE READ CAREFULLY BEFORE COMPLETING THIS APPLICATION Esperanza Health Systems, Ltd. complies with all Federal and State laws regarding discrimination on the basis of race, color, religion, national origin, sex, disability, age if over forty, and any other characteristic protected by law. No question on this application is intended to secure information to be used improperly. Should you need assistance or accommodation in completing this application, please notify the receptionist. Receipt of this application does not imply that there are any positions open, or that an applicant will be employed. Only applicants meeting the minimum requirements for a position, as determined by Esperanza Health Systems, Ltd. will be considered for employment. Should more than one qualified person make application, Esperanza Health Systems, Ltd reserves the right to elect the applicant, in its' opinion, with the best qualifications. A clear understanding of your background and work history will aid us in assessing your qualifications. Please PRINT all information in ink. Name: First Middle Last Other names used in prior employment: Present Address: Number Street City State Zip Telephone Number: ( ) Address: Please list all states of previous residency: Are you 18 years old or older?: [ ] Yes [ ] No Have you ever worked for La Hacienda? [ ] Yes [ ] No If yes, when? Type of Employment requested: [ ] Full-Time [ ] Part-Time [ ] Occasional [ ] No preference Shift Availability: [ ] Day [ ] Evening [ ] Night [ ] Weekend Position Applied For: Category Position [ ] Management [ ] Licensed Professional [ ] Clerical [ ] Clinical or Nursing support [ ] Other

4 ESPERANZA HEALTH SYSTEMS, LTD. DOES BACKGROUND CHECKS AS WELL AS DRUG TESTING. FAILURE TO ANSWER ANY QUESTION TRUTHFULLY AND FAILURE TO REPORT ALL CONVICTIONS WILL RESULT IN DISQUALIFICATION OF APPLICANT OR IMMEDIATE DISMISSAL OF EMPLOYEE. DO NOTANSWER THE QUESTIONS ON THIS PAGE IF YOU ARE APPLYING FOR A POSITION IN AUSTIN. Have you ever been convicted of, plead guilty to, or received deferred adjudication for any crime (misdemeanor or felony including but not limited to any DWI convictions)? [ ] Yes [ ] No If yes, please give dates, level of charge, and details of EACH conviction: Date of conviction Location of conviction (City, County, State) Level of Charge (Misdemeanor or Felony) Type of Charge (i.e. Assault, DWI, etc.) All convictions must be listed, please attach additional copies of this form if necessary. Conviction of a crime does not constitute an absolute bar to employment; however, all convictions (misdemeanors or felonies) must be listed, whether or not expunged from your record. Deferred adjudication is not considered a conviction and need not be listed.

5 Education: Please list name and location of school/college/university with GED, diploma or degree awarded. Name of School/College/University Address (Street/P.O., City, State, Zip) Major Did you Graduate (yes/no) Type of Diploma/Degree Awarded Other specialized training or skills: Computer skills and typing skills: Typing wpm Please check all computer programs you have experience with: [ ] Windows [ ] Word [ ] Excel [ ] Outlook [ ] Access [ ]Powerpoint Please list all other programs that may not be mentioned above: Other Office Equipment: Drivers License State: Current License # Expiration Date For Professional Personnel Only: Licensed as: State: Current License #: State: Current License #: State: Current License #: Have any license privileges been suspended or revoked? [ ] Yes [ ] No If so, why and where?

6 EMPLOYMENT RECORD: Starting with Present or Most Recent list ALL EMPLOYERS FOR THE PAST 10 YEARS. Include self-employment, summer, part-time jobs and any period of unemployment. If you need more space, please continue on a separate sheet. Please indicate any change of name or assumed name used in work experiences. Name & Address of Company: Employed from: to Phone: Ending Salary: Reason for Leaving: Position held: Name of Supervisor: Description of Duties: Name & Address of Company: Employed from: to Position held: Name of Supervisor: Description of Duties: Phone: Ending Salary: Reason for Leaving: Name & Address of Company: Employed from: to Position held: Name of Supervisor: Description of Duties: Phone: Ending Salary: Reason for Leaving: Name & Address of Company: Employed from: to Position held: Name of Supervisor: Description of Duties: Phone: Ending Salary: Reason for Leaving:

7 Have you ever been fired from a job or been forced to resign? (this includes all jobs, not just the ones listed on this application) [ ] Yes [ ] No If yes, please give details for each occurrence: If you are employed now, may we contact your employer? [ ] Yes [ ] No If presently employed, why do you desire to change your position? I authorize investigation of all statements contained in this application (if I am considered for employment) and hereby authorize Esperanza Health Systems, Ltd. to make investigation of my past employment (and current employment, if indicated above that this would not pose any difficulty), educational, professional licensing, or criminal history through any investigative agencies or bureaus of its choice. I release all relevant parties from all liability damages resulting from furnishing such information. In the event of my employment to a position at Esperanza Health Systems, Ltd., I will comply with all rules and regulations as set forth in Esperanza Health Systems, Ltd. policy manual or other communications distributed to all employees. I agree to complete a health evaluation, which may include a physical examination by a doctor selected by Esperanza Health Systems, Ltd. (at Esperanza Health Systems, Ltd.'s expense). Additionally, I authorize Esperanza Health Systems, Ltd. to supply my employment record in whole or in part, as necessary for effective business operations, as may be required by law or regulations or to assist in regulatory agency investigations. Also, if employed by Esperanza Health Systems, Ltd., I grant permission to use my photograph in connection with its advertising and public relations programs. I hereby certify that I have read all of the above statements and understand the same, and that all statements made by me are true and accurate to the best of my knowledge and that I have withheld nothing that would, if disclosed, affect this application unfavorably. I understand that any false statements of material or omissions may be grounds for refusal to hire, or for immediate dismissal. Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between Esperanza Health Systems, Ltd and myself for either employment or the providing of any benefit. Employment at Esperanza Health Systems, Ltd will be for no definite term and either I, or Esperanza Health Systems, Ltd have the right to terminate the employment relationship at any time, with or without notice and with our without cause. I also understand that this status can only be altered by an enforceable written agreement, which is specific as to all material terms and is signed by a member of the Governing Body of La Hacienda Treatment Center. I further acknowledge that no promises regarding employment have been made to me, and that no promise or guarantee is binding upon Esperanza Health Systems, Ltd unless made in an enforceable written agreement. Applicant's Signature / / Date

8 EEO-1 Voluntary Self Identification Form Legal Name: Last First Middle Esperanza Health Systems Ltd. D.b.a. La Hacienda Treatment Center is required to collect information on ethnicity and race for all applicants and staff. This information is used for state and federal accountability reporting, as well as for reporting to the Office of Civil Rights (OCR) and the Equal Employment Opportunity Commission (EEOC). Completion of this form is voluntary and will not affect your opportunity for employment, or the terms or conditions of your employment. This form will be used for EEO-1 reporting purposes only and will be kept separate from all other personnel records only accessed by the Human Resources department. GENDER: (Please check one of the options below) Male Female RACE/ETHNICITY: (Please check one of the descriptions below corresponding to the ethnic group with which you identify.) Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. White (Not Hispanic or Latino): A person having origins in any of the original peoples of Europe, the Middle East or North Africa. Black or African American (Not Hispanic or Latino): A person having origins in any of the black racial groups of Africa. Native Hawaiian or Pacific Islander (Not Hispanic or Latino): A person having origins in any of the peoples of Hawaii, Guam, Samoa or other Pacific Islands. Asian (Not Hispanic or Latino): A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam. Native American or Alaska Native (Not Hispanic or Latino): A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment. Two or more races (Not Hispanic or Latino): All persons who identify with more than one of the above five races. I do not wish to disclose.