Page 1 of 2 ciel Corse Lataton jon edealConter-Ledngton iS Lexington metal Cente Tour partner for! anid weHtness Application for Employment a A Laxington Medical Centar fs an eal Oppotuin and pledoes to provid eterna ee eee color, ralighor Spe. ony ralenal origin seal or veteran's sates Lalegion Medel Cen ‘Aasgust 2008 * required information . Notice/Authorization for Release of Information for Employment Purposes Investigative Consumor Report - it ay ith Lexington Medical Center, | authorize Lexington sss cuenta mnsumer report about my background, character or rena reset aca Se ,, Investigative ae Information aso my employment, education, consumer credit history, diving record, Soci sera ‘number verification, criminal record and/or other ree reson nee Ss Toney a His authorization format to this investigation. | fu Say be caplited onto understand that all offers of employment are contingent upon the ey of this background investigation. have read and-understand this statement and. \ authorize, ‘any person, agency or other entity contacted by Lexington Medical Genter, Backgroun 7 Inc,, or its agents, fo furnish the above-mentioned jnformation. FirstName: Nikkl Ml: R Last Name: Haley ‘Social Security Number: Diver's License Nunber State: so yor Names used (alas, maiden, cmon 3 nickname): Current Address: 240 Governors Grant Blvd City: Lexington Stato: SC Zip: 29072 Previous addresses (for the past seven years) RaineyProd 0045 Page2 of 2 State: Dates Lived Here: Address: ci State: Zp: Dates Lived Here: Z ADDITIONAL INFORMATION Please answerall cf the following questions. No Have you ever been convicted of or plead guil a imme (anything other than a. ralnortafte lato)?” cee ere Ayes ee No Have you ever been convicted ina military court marital? No ‘Are you currently under any investigation or pending charge? No Have you ever been sanctioned, disci; 1ed, debarred and/or authorized regulatory agency? sal ee No Jsyourlcensecerticatoncuenlly Ina probatonary ott, rotted orinited In READ AND SIGN Read the following carefully before signin: | cary thatthe information contained on ths forn fs true and correct and I understand Sx cmnlerent lb emincedtaod ony ase, nitedrfauentinoratan Pathog understand tha fis Authrzafon/Roleaso orm shal remain in oflc ortho duration of my emplyrmont My typed name below shall have the same force and effect. is my written signature, CCandldate's/Applcant’s Signature: Nikki R. Haley Date: w a Ce Ker hitps://wwrw.healthcaresource.com/lexmed/adminvindex. cfin?fuseaction=applicant viewCust., 8/6/2008 we Job Application Page lof 5 Beaton Apa Far Position: Superviser PFS INC Louis Faclge Ledhston Madioal Cantor Leington ington. Medical Center Desa cingtn Nel Cntr -haington rt Care Jove parhiee for bealth and wollness vga oqNone 8168 ae ue eran et ant em, idercelpeties tones onsen gence neat oat ny tt = rene areca scone * required information |GENERAL INFORMATION ” Fest Name: * NIKKI Mi R Last Name: * Haley Social Security Number: * “** Ust cthernames under which your records may be found: Present Address: * $40 Governors Grant Blvd city: * Lexington Stato: * SC Zip: * 28072 County: Lexington Business Phone: snot Aces: cond conden oral Ns a) ‘atdross? . enter your highest level of education, [EDUCATION - Pt |All fields are required In the row with *. If no information Is available, please enter N/A. Dogras or , Coussot oid you nal Level Hama of Scho ‘ty and’ state Obploms, Educational Level of Scheot ty an ‘Study = graduater ——_blama Mh scot ™ Orangeburg Prep HB Orangeburg,8C General Yes —_-H8 Diploma ‘Clemson Univ Clemson,SC Accounting Yoo BS SKILLS / EXPERIENCE Attps://www.healthcaresource.com/lexmed/admin/index.cfm?fuseaction=applicant.viewCust... 8/6/2008 RaineyProd 0043 «Job Application Page? of 5 . Q) media Q ( Peditics Q suet O)einargney Department QNentom tursery CQ) oncoteay QC outpatient Surgery Q) Special Care Nusery Q Piimonary Q Operating Room Ooncn O) crthopeicaotsy recovery tiem O Teamatyircu Obitora Daivery spc sae, experiance, uit edueaon causes, prpestralogataton, ity taba repens ofr hh younave appa (Onan wih rthda yur aca, cen wigan etn stfanaon maha Sater LICENSES [Professional Licensure “First row Is required, please enter N/A if this section is not applicable censulCentinten ‘utlicanse No, —alaYuarInaved —phaton Date Temperary Permanent na na na na Oo Oo Oo OQ Oo oO [e} Oo WORK HISTORY List Errployers beginning with most recent Explain any periods of unemployment not related to school. It resently employed, may your employer be contacted at ths ie fora roferenco? * Yoo If no information fs available, please enter N/A. NOTE: Ifyouhave a resuma, ths information is stil required, Do Not enter "see resuma”, 4.Most recent employer Name ot Company: * Exotica international ine Jeb Duos end Reaponsbiten: * Peer osrd'aaest ana All accounting functions and reporting. ciy.Stat zp: * West Columbia, SC 20169 erin mekeana: rua) | Employers Phone: * 803-986-5650 Reason for Leaving: * lotr Ware) Used: * NA Business retirement job me: * CFO From (motn): * 1998 To (raty:* 2008 nog Gary * 125,000 supenisors ane: * Dr. and Nrs. AS Randhawa erptymone stat: * full time empanr: SC House of Roprosontativee Job Duta and Responses: otostAddess: 320D Blatt Reprosentng th consents of Dstiet cry, stot, 9: Coluribla, SC 29211 Resa tc ee LY https://rww healthcaresource,com/lexmed/admin/index.cfin?fuseactionapplicant, viewCust... 8/6/2008 ! \ RaineyProd 0044 Job Application Pages of 5 Employers Phone: 803-734-2970 eter Hara Jeet NA ob Te: Rop for Dist 67 From, an ro cnet Enang Sao Supervisors ane: [Employment Sates: part time 3. {ob Dstes ond Reapers: acer Responsible for the allaccounting city, State, Zip: Charlotte, NC functions and reporting of the corporation Employer's Phere: and 6 subsidiaries, Steff manager of ete tena NK Rance Accounteg Dept ob mae: Accounting Supervisor Reaeon or [From (mofyr): 1994 Moved to SC Grmotyn): 1998 Ena Sane supervisor's Name: Douglas Handy rpoyment stats fll fim S Job Ditlos and Rasponsibildias: ame etcempane Strack Ades: Reason forLeavon: MILITARY SERVICE It you have military experience, a copy of your discharge paperwork will be required. RESUME Resume ‘To cutand paste your resume: 4. Highlight the text on the resume you want to copy. 2, Press'Cirl C'to copy (Hold down the Ctl key and press C). 3. Place the cursor in the RESUME box below. 4. Press ‘Cirl V'to paste the information. Cover Letter REFERENCES [Please list 3 professional references, This should be people with whom you have worked in prior Jobs or hittps://www-healthcaresource,com/lexmed/admin/index.cfn?fuseaction~applicant.viewCust.... 8/6/2008 RaineyProd 0047 Job Application Page 4 of $ lmay be professors, teachers or instructors. Do not Include personal roferonces, Nawve * Company and Addrass™ Prasent THe ™ Phone Number * ‘Ted MoGee McGee Real Estato President 739-0550 Richard Jackson ‘OR Jackson President 920-4170 Mike Sisk Ben Amold Dist CFO 767-8630 ADDITIONAL INFORMATION What is your expected salary? 125,000 LUst days you are able to work: ‘Monday thru Friday | How did you find out about this position? * Other Please enter "Other" source: Nike Blediger ‘Ifemployee referral, please enter name Which Job status/shift would you accept? sate san (loose check all Gat opel) (X) Ful Tine 1ST SHIFT Orartine 210 SMF Oran Q sro shir (CQ) WeeKenps: Orextme Qrorarnna Please answer all of the following questions, ‘Aro you or will you be a recent graduate from a Registered Nursing Program? tyes, No* Were you previously employed by Lexington Medical Center? ys, dates? Doyou have any relatives employed at Lexington Medical Centor? yea, whe? No* No* lo* Have you ever been disciplined or fred? We an eeba arate * Ara you legally oligible for om; 1ent in tho Urited States? ee Aree unin a Soho ae te tye Have you ever been convicted of anything other than minor traffic volatons or a heath relation crime or are you listed as debarred, excluded or otherwise Ineligible for patipate in federal health ans? ten enn exlnty arg tootumw ane Boca (Convitonet a cime ls noten automatisbar fo ompoymentothor teumstancas wil be considered) No* + Wlyou have any cieuttes in gottng to work? Gp {yvepieam expan y ttps://www.healthearesource, com/lexmed/admin/index.cfin?fuseaction~applicant,yiewCust,,.. 8/6/2008 RaineyProd 0048 Page 5 of 5 = Tob Application READ AND SIGN Read the following carefully before signing. | certify that the information | have given on this appication is accurate and complete to the best of my knowledge and belief, | understand any misrepresentation of fact as stated or Impied, given in my. application, interview(s), or any other employment form or document provided to me by Lexington Medical Center may be sufficient reason not to hire me or may bo' Investigated by Lexington Medical Genter and ‘agree that all information furnished in this application may be investigated by Lexington Medical Center or its authorized reprosentatives. | hereby authorize all individuals In organizations named or referred to In the application and any law enforcement organization to give Lexington Medical Center all information that relates to or is requested during an investigation, ard J hereby release these individuals, organizations, and Lexington Medical Center from any and all lability for any claim or damage resulting there from. { understand that Lexington Medical Center is not obligated to provide employment and that| not obligated to accept employment. Nothing In this application or In any prlor er subsequent oral or writen statement of ‘communication is intended to create any contract of employment orto create any righisin the nature of a conlract, This applaton does not bind either party for a specific perad oftime regarding ermploymont. also understand thatno one has the authority to enter into an agreement, contract, or madification ofthe understandings oxpreseed in thie statomont unless itia in writing and signed by the President and CEO of Lexington Medical Center. fired, ! understand that nothing shall restict my right 2s an employee o the sight of Lexington Medical Center as an employer to terminate my employment at any time for any reason, |lunderstand that any offer of employment is conditional on satisfactory replies from references and satisfactory results from physleal examination, which inclides blood and/or urine toets to detect the presence of illegal drugs or aleohol, Furthermore, if lam employed, J understand that {will have the right to {terminate my employment at any time with or witiout notice, end with or without cause and Lexington ‘Medical Center has the same right. I hereby acknowledge that | have read the above statement and I understand and accopt them, My typed name below shail have the same force and offect as my written signature, Candidate's/Applcants Signature: Niki R. Haley Date: 08/05/2008 pe RaineyProd 0049