Dear Pharmacy Technician,

Hello! Thank you for your interest in RPh on the Go. We are excited to share the opportunity for a rewarding
career with you.

We have a few requirements and forms for you to complete and return to us in the enclosed envelope:
‰ Application Packet — includes a general job description, required HIPAA training, application for
employment, skills checklist, a variety of authorization forms. Please complete the application, skills
checklist and sign the authorization forms and return them to us in the enclosed envelope or via email or
fax.
‰ W-4 — Please complete the bottom portion and return it with your application.
‰ Direct Deposit Application — If you would like your paychecks deposited electronically, please complete
the application for direct deposit.
‰ Resume — Please include a copy of your current resume.
‰ State certification, registration or license — Please include a copy of your applicable state license,
certification or registration.
‰ CPhT certification (if applicable) —If you are certified with PTCB, please include a copy of your current
certificate.
‰ I-9 Form — Please review the instructions for the Employment Eligibility Verification (I-9) form carefully.
We must receive your Employment Eligibility Verification (I-9) soon after the first day you work for us. If
you are not in the Skokie, Illinois area, please take this form and the required supporting documents to a
trusted, non-family friend or colleague on your first day of work with us. This person will review the
documents, complete the Section 2 and Certification sections (they are acting as our “agent”). Please FAX
a copy to us immediately and send the original to us in the second envelope. If you are in the Skokie,
Illinois area, please call us to arrange a time to come to our headquarters to complete this process.

Also, some of our clients may require additional materials from you, such as a recent TB test, MMR, proof of
varicella immunization, proprietary training on their systems and processes, a physical exam or other
requirements. We will contact you as these items are needed and in many cases, we will help make
arrangements for completing the requirements.

Thank you for your interest in working with RPh on the Go. Please feel welcome to sign-in at
www.rphonthego.com and update your availability calendar and register your email address for updates.

Thank you for joining our diverse and dynamic healthcare team. Please call me at 800-553-7359 with any
questions.

My best,
Steve
Steve Sidell
Director, Quality Assurance & Compliance

enc.

8001 N. Lincoln Avenue

Suite 800
Skokie, IL 60077
800.553.7359 office
847.588.7060 fax
www.rphonthego.com
Job Title: Traveling Pharmacy Technician
Reports To: Career Advisor
Updated Date: December 2009

Position Summary:
This is a per diem position for a pharmacy technician to provide professional services to a variety
of clients on behalf of RPh on the Go.

Duties and Responsibilities:

x Maintains active state or national certification, as required.
x Provides required health records, as determined by assignment.
x Submits to requested drug screening(s).
x Provides professional pharmacy technician cognitive services, which can include:
 Retrieving prescription orders
 Counting, pouring, measuring and weighing tablets and medications
 Mixing medications
 Creating prescription label
 Filing
 Preparing insurance claim forms
 Providing customer service: telephone and cash register
 Maintaining inventory of OTC medications
x Completes pre-assignment training requirements.
x Each assignment that you accept will be performed by you to its completion.
x Provide service to those assignments that you feel comfortable with and capable of
performing at a maximum professional level.
x Comply with all applicable State laws and pharmacy regulations in the states where you are
working.
x Communicate with your Career Advisor and other RPh on the Go staff.
 Maintain accurate contact information with RPh on the Go.
 Immediately inform your Career Advisor or someone else on the RPh on the Go staff of
any adverse event, injury, or a concern about your working condition or assignment.
Please refer to the Employee Handbook for emergency contact information.
x For each assignment:
 Punctuality: Allow enough time to arrive and orient yourself to the facility before the
scheduled start-time.
 Timecard: Submit a weekly timecard for each client, following the guidelines in the
employee handbook.
 Cooperation: Work in conjunction with the client staff at each assignment to provide the
highest quality healthcare.
 Dress code: Present yourself in a professional manner, in accordance with client
requirements.
 Customer service: Provide the highest level of customer service possible.

Required Qualifications:
x Required Pharmacy Technician training; national or state certification as required
x Must be eligible to work in the United States

Language Skills:
Ability to read, speak, and write in English. Ability to read and interpret documents such as safety
rules, pharmaceutical documents and procedure manuals. Ability to write routine reports and
correspondence. Ability to effectively present information and respond to questions from patients,
coworkers and other healthcare professionals.

Physical Demands:
Physical demands vary on a per-assignment basis. Reasonable accommodations may be made
to enable individuals with disabilities to perform the essential functions.
Pharmacy Technician Employment Application
RPh on the Go is an equal opportunity employer and does not discriminate on the basis of race, religion, color, national origin,
age, sex, gender, disability or any other characteristic protected by law.

PERSONAL INFORMATION (please print)

First Name:___________________________ MI: ________ Last: __________________________ Suffix: _____
How should your first name appear on your nametag? _______________________________________________
Address: __________________________________________________________________________________
City: ________________________________________ State: _______ Zip Code: ________________________
Social Security #: _________________________ Driver’s License #: _____________________ State: ________
List any other names (including maiden names) or social security numbers you have used: __________________
__________________________________________________________________________________________
Home Phone: _________________________________ Work Phone: __________________________________
Cell Phone:___________________________________ Email: ________________________________________
Emergency contact: _________________________________________________________________________
Relationship: ______________________________ Telephone: _______________________________________

EDUCATIONAL AND PROFESSIONAL INFORMATION

Please include your resume, with your complete educational background.
High School Name: ___________________________________ Graduated or GED? € Yes € No
College: _______________________________ Graduated? € Yes € No Degree earned _________________
Pharmacy Technician Training Program: __________________________________________________________
Certification: € CPhT - Certification ID number and expiration: ________________________________________
Please list all active and inactive state pharmacy technician licenses or registrations:
Disciplinary Action
Technician License or Expiration reprimand, probation, suspension, voluntary surrender, revocation
State
Registration Number Date Past Disciplinary Current Disciplinary
Action Action
€ No € Yes* € No € Yes*

€ No € Yes* € No € Yes*
€ No € Yes* € No € Yes*

* Year of Disciplinary Action: ____________________ Explanation of past or current license disciplinary actions
(attach a separate page if necessary): _________________________________________________________________
__________________________________________________________________________________________

PHYSICAL RECORD
Do you need any special accommodations to perform the essential functions of your job? € Yes € No
If yes, please describe accommodations needed: ___________________________________________________
__________________________________________________________________________________________
Name: ____________________________________________________________________________________

WORK EXPERIENCE
Please list your three most recent pharmacy-related positions or other employment. Please attach a copy of your
current resume.

CURRENT EMPLOYER: ______________________________________________________________________

Please list any requests for contacting your current employer: _________________________________________
__________________________________________________________________________________________
Type of Business: € Retail € Long-term Care € Hospital Out-Patient € Hospital In-Patient € Home Infusion € Mail-Order € Other
Address: __________________________________________________________________________________
City: __________________________________ State: _______ Phone Number: _________________________
Position: ____________________________________________ Salary: ________________________________
Dates Employed: from ________ to ___________ Reason for Leaving: ___________________________________
1) Supervisor or peer who can serve as a reference: _______________________________________________
Title: __________________________ Work Phone: ___________________ Cell phone: ________________
Email: __________________________________ Dates worked together: ____________________________
2) Supervisor or peer who can serve as a reference: _______________________________________________
Title: __________________________ Work Phone: ___________________ Cell phone: ________________
Email: __________________________________ Dates worked together: ____________________________

EMPLOYER: _______________________________________________________________________________
Type of Business: € Retail € Long-term Care € Hospital Out-Patient € Hospital In-Patient € Home Infusion € Mail-Order € Other
Address: __________________________________________________________________________________
City: __________________________________ State: _______ Phone Number: _________________________
Position: ____________________________________________ Salary: ________________________________
Dates Employed: from ________ to ___________ Reason for Leaving: ___________________________________
1) Supervisor or peer who can serve as a reference: _______________________________________________
Title: __________________________ Work Phone: ___________________ Cell phone: ________________
Email: __________________________________ Dates worked together: ____________________________
2) Supervisor or peer who can serve as a reference: _______________________________________________
Title: __________________________ Work Phone: ___________________ Cell phone: ________________
Email: __________________________________ Dates worked together: ____________________________

EMPLOYER: _______________________________________________________________________________
Type of Business: € Retail € Long-term Care € Hospital Out-Patient € Hospital In-Patient € Home Infusion € Mail-Order € Other
Address: __________________________________________________________________________________
City: __________________________________ State: _______ Phone Number: _________________________
Position: ____________________________________________ Salary: ________________________________
Dates Employed: from ________ to ___________ Reason for Leaving: ___________________________________
1) Supervisor or peer who can serve as a reference: _______________________________________________
Title: __________________________ Work Phone: ___________________ Cell phone: ________________
Email: __________________________________ Dates worked together: ____________________________
2) Supervisor or peer who can serve as a reference: _______________________________________________
Title: __________________________ Work Phone: ___________________ Cell phone: ________________
Email: __________________________________ Dates worked together: ____________________________
Pharmacy Technician Employment Application page 2
 PharmacyTechnician
SkillsChecklist

Instructions: Please complete the following skills checklist by placing an "X" in the column which most accurately indicates your
level of experience with each listed item. The correlation between the numerical scale and level of experience is as follows:
1 - No Experience (Would require substantial training and instruction to perform independently).
2 - Minimal Experience (Would require supervision before performing independently).
3 - Moderate Experience (Would require a brief review before performing independently).
4 - Significant Experience (Can perform independently).

_________________________________   _______________________
First and Last name (please print clearly) Date
PRACTICE SETTING 1 2 3 4 AUTOMATION 1 2 3 4
Independent Community Compounding Systems:
Retail/Chain - Baxa Rapid Fill (ASF)
Hospital Inpatient (HIP) - Baxa Repeater Pump
Hospital Outpatient (HOP) - Baxa ExactaMIX
Home Infusion/HomeHealth (HI) - Baxter AUTOMIX/MICROMIX
Long Term Care - Other (please list):
Mail Order
Other (please list): Dispensing Systems:
- Pyxis
GENERAL SKILLS 1 2 3 4 - Omnicell
Computer skills - Parata RDS
Prescription data entry - Parata MAX or Mini
Creating new patient profiles - McKesson PACMED
Call physicians for refill authorization - McKesson MedCarousel
Interpret prescriptions for accuracy - McKesson PROmanager
Prepare and fill prescriptions - Other (please list):
Third Party Billing/Adjudication
Brand/Generic Equivalence Knowledge Tablet Counting System:
Compounding/Oral Suspension Reconstitution - Kirby Lester
Cart fill - TORBAL Rx Balances
Unit dose preparation - Baker Cells
Proper storage of medications SOFTWARE SYSTEMS 1 2 3 4
Ordering/Inventory Control Cerner
Knowledge of controlled substances Epic
Pseudoeph/ephedrine, etc laws/regulations McKesson (Pharmserv, 3PM)
Disposal of hazardous waste/materials MEDITECH
Parenteral Product Preparation (IV’s) Connexus
Pharmaceutical Calculations Nexgen
Other (please list): PDX
QS-1
CREDENTIALING/POSITIONS HELD YES NO EnterpriseRX
Current CPhT PROscript 2000
Licensed/Registered by State Other (please list):
Staff Technician
Lead Technician HIP/HI/IV EXPERIENCE 1 2 3 4
Senior Technician Aseptic Technique
Other (please list): Laminar Flow Hood
TPN Preparation
Chemotherapy Preparation
Number of years working as a Technician Antibiotic Preparation
Name: ____________________________________________________________________________________

Terms and Agreements

By signing below, I agree to the following list of terms and agreements:
x I certify that the facts contained in this application are true and complete to the best of my
knowledge and understand that, if hired, falsified statements on this application can be grounds for
dismissal.
x HIPAA: I have reviewed the training material regarding the implementation and legal consequences
of HIPAA, Title II. I understand that I am responsible for reviewing each client’s procedures on
protecting the patient’s private health information.
x PURPOSE: RPh on the Go was formed to provide licensed/registered Pharmacy Technicians in
good standing with a source of temporary employment. By signing this Agreement, you represent
that you are such a Pharmacy Technician and you agree to furnish pharmacy services performed
by you to our Clients as an employee of our company. We will offer these assignments to you so
that we mutually can fulfill our contractual obligations to these Clients.
x COMPLIANCE: Each assignment that you accept will be performed by you to its completion. You
only need to service those assignments that you feel comfortable with and capable of performing at
a maximum professional level. In providing these services, you agree to comply with all applicable
State laws and pharmacy regulations in the states where you are working.
x WAGE AND TIMECARDS: We will pay you a base rate, negotiated at the time of agreement for
each assignment. Additional compensation you might receive is reimbursement for distances
traveled from your home, room and board (if overnight accommodations are necessary and
approved), required “on call” time, appropriate pre-approved overtime work, and special rates for
certain specific jobs. These “extras” will be agreed upon by us before any services are rendered by
you. We will be fully responsible for these compensations once confirmed. When you provide
pharmacy services to our Clients, you will provide us with signed time cards for the work once
completed. You shall make no schedules or schedule changes without written confirmation by RPh
on the Go.
x INSURANCE: If you drive a car to work, your responsibilities include maintaining current and
adequate auto insurance.
x DISCIPLINARY ACTIONS: If any disciplinary action has occurred that affects your ability to perform
as a Pharmacy Technician in good standing, we must be immediately informed by telephone and in
writing. These changes may affect any future assignments we can offer you.
x NON-COMPETE: During the term of an assignment and for twelve months following termination of
an assignment, you agree that you will provide pharmacy services to our Clients only through our
service. You agree that you will not provide pharmacy services to such Clients directly or indirectly
(as an employee, independent contractor, etc) for that twelve-month period. Our contract with the
Client prohibits the Client from hiring you without paying a permanent placement fee to our
company. Therefore, if prior to the expiration of these twelve months a Client wants to hire you (as
an employee or independent contractor, etc), you agree to immediately notify us. In our sole
judgment, we may waive the twelve-month non-compete clauses provided we enter into a
satisfactory compensation agreement with the Client or you.
x TERMS: This Agreement shall continue until (a) in our judgment, it is violated; or (b) thirty days
written notice is given by either party to terminate this Agreement. In either event, you agree that
the twelve month non-compete clause set forth above shall survive the termination of this
Agreement. This Agreement describes the entire obligation of each party to the other and can only
be changed in writing by both parties.

Pharmacy Technician/Employee Signature: _____________________________________________________
Print Name: ______________________________________________________ Date: _____________________
RPh on the Go USA, Inc. Signature: _____________________________________________________________
Print Name: ______________________________________________________ Date: _____________________

Pharmacy Technician Employment Application page 4

RPh on the Go Mandatory Training:
HEALTH INSURANCE PORTABILITY & ACCOUNTABILITY ACT OF 1996

Please read the following information about the Health Insurance Portability and Accountability Act of 1996. By
signing the following page, you acknowledge that you are responsible for upholding the HIPAA guidelines and
reviewing each client’s procedures on protecting the patient’s private health information.
What is the purpose of HIPAA?
x To provide health insurance portability from one employer to another
x To improve healthcare efficiency by standardizing the exchange of medical information
x To protect the patient’s privacy against the misuse or improper disclosure of health records
Who is affected by HIPAA?
All employee pharmacists, relief pharmacists, owner pharmacists, consultant pharmacists, health care system pharmacists,
interns, health care providers, health plan administrators, pharmacy technicians & support staff, who may have access to a
patient’s health information.
What is the definition of Personal Health Information (PHI)?
Any “individually identifiable” health information transmitted through conversation, computer, or paper. This includes
conversations with a patient, physician, nurse, clinic, health insurance representative, or pharmacy technician. Identifiable
information includes a patient’s name, address, social security number, e-mail address, photograph, date of birth, gender, fax
or phone number, driver’s license, or relative’s name. HIPAA does allow the use or disclosure of PHI to provide treatment, to
collect payment, and to conduct health care operations. Treatment is defined as dispensing, DUR counseling, disease
management, & refill reminders. Collecting payment is defined as verifying insurance coverage, reconciliation of claims, and
third party billing. Operations are defined as malpractice insurance and hardware/software/database management. In addition,
you may disclose PHI when required by law enforcement investigations, court orders, subpoenas, government benefit
programs, State Boards of Pharmacy, the FDA for adverse events or product defects/recalls, or the Department of Health or
CDC for disease or injury reporting.
How does HIPAA affect pharmacy operations?
When you counsel a patient (either in person or on the phone) regarding their medication, you should keep your voice low and
attempt to do so in a discreet area, so others cannot eavesdrop. PHI should not be within open view of other patients, guests,
customers, pharmaceutical sales reps, or delivery personnel. At the start of any assignment, it is imperative that you review
each client’s operations policies regarding documents and prescription vials containing PHI. Most pharmacies staple the
prescription receipt on the outside of the bag for identification purposes. To protect the patient’s privacy, the pharmacy may
use a smaller type font, so this information is not so visible. At the register checkout, the pharmacy may place the receipt
inside the bag or fold the receipt inside out and staple it to the outside of the bag. To discard paper documents containing PHI,
either tear or shred the document. Either return the old vial to the customer or destroy the label before tossing any vial.
What is the Notice of Privacy Practices (NOPP)?
Effective with any prescriptions filled after 4-13-03, HIPAA requires that you post a copy of the Notice of Privacy Practices in
the pharmacy and provide a copy to each patient. This notice describes the patient’s privacy rights and explains how the
pharmacy intends to use and disclose PHI. You must attempt to obtain the patient’s written acknowledgement that he/she has
received the pharmacy’s privacy policy. If the patient refuses to sign, you are required to document your efforts to obtain a
signature and the reason why the patient did not comply. A parent or guardian may sign for a child’s prescription. If requested
by the patient, you are required to provide a written accounting of disclosures of PHI and the pharmacy’s prescription records
for up to 6 years prior to the date of request (but not prior to HIPAA’s effective date of 4-13-03). Patients may request
additional restrictions on the use or disclosure of their PHI and the type of communications they prefer. Please familiarize
yourself with and follow the client’s procedures.
Complaint Procedures
If a patient feels the pharmacy has breached their privacy by inappropriately sharing their PHI, communicate that the
pharmacy makes every attempt to respect their right to privacy. If the patient decides to pursue this further, provide the contact
information as described in Notice of Privacy Practices. In addition, a formal complaint may be filed with the Secretary of
Health & Human Services (listed on the NOPP).
How does HIPAA affect state laws?
HIPAA is a federal law that supercedes less stringent state laws, but not more stringent state laws. What are the legal
consequences of non-compliance with HIPAA?
x Civil penalties up to $25,000 per rule violation.
x Criminal penalties up to $50,000 and one year in prison for knowingly and improperly obtaining or disclosing private
health information.
x Up to $250,000 fine and 10 years in prison for the sale, use, or transfer of private health information for personal gain
or malicious harm.
x Sanctions apply to individual employees, not just the pharmacies.

Please keep this for your records.

 BACKGROUND SEARCH DATA FORM
The purpose of this form is to gather the information necessary to conduct your post-offer background search. All employment is contingent upon
favorable background search results. All information will be kept confidential.

1. CANDIDATE INFORMATION
Candidate Name:
Current Street Address:
City, State, Zip code:
Social Security #:
_____________________________________________________________________________
First Middle Last
_____________________________________________________________________________
_____________________________________________________________________________
__________________________________

Driver’s License #: __________________________________ State Issued: _____________________

2. THE FOLLOWING IS FOR IDENTIFICATION PURPOSES ONLY TO PERFORM THE BACKGROUND CHECK

Race: (Circle one) Caucasian Black / African American Indian Hispanic Asian / Pacific Islander American Indian

Gender: (Circle one) Male Female Date of Birth:____________________________

Additional Names
Used in past 5 years: _____________________________________________________________________________________

3. LIST ALL CITIES, COUNTIES, STATES AND COUNTRIES WHERE YOU HAVE RESIDED DURING THE PAST 5 YEARS
OR NUMBER OF YEARS AS DETERMINED BY CLIENT:
CITY/PROVINCE COUNTY STATE COUNTRY* APPROXIMATE DATES

x If you have lived outside the United States you will be contacted for additional information

4. Educational Data
School Print Name Of School City, State and Zip Years Attended Did You Degree Type
(i.e. 2002-2004) Graduate? (i.e. BS,MBA)
College or Yes
University No
Other Yes
College/Graduate No

5. I certify that the above information is correct:

Signature: _____________________________________________

Print Name: _____________________________________________

Date: _____________________________________________

BRANCH INFORMATION – FOR INTERNAL USE ONLY

Business Unit Name: ____________ Branch Number: ___________________ Title Applied for: ________________________________

Branch/Dept. Contact: _____________________________ Start Date: ____________________ Starting Salary: _____________________

All MPS Companies/ Background Search Data Form Rev. 05/2009

 DISCLOSURE AND AUTHORIZATION
[IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION]
DISCLOSURE REGARDING BACKGROUND INVESTIGATION
Adecco Group NA (“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 First Advantage P.O. Box 105292, Atlanta, GA 30348,1-800-845- 6004.
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.

New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any
investigative consumer report requested by the Company by contacting the consumer reporting agency identified above
directly. You may also contact the Company to request the name, address and telephone number of the nearest unit of the
consumer reporting agency designated to handle inquiries, which the Company shall provide within 5 days.

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 First Advantage P.O. Box 105292 Atlanta, GA 30348, 1-800-845-6004, another outside organization acting on behalf of the
Company, and/or the Company itself. Their Privacy Policy can be reviewed at http://www.fadv.com/privacy-policy/. I agree
that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

New York applicants or employees only: By signing below, you acknowledge receipt of Article 23-A of the New York
Correction Law.
Minnesota and Oklahoma applicants or employees only: Please check this box if you would like to receive a copy of a
consumer report at no charge if one is obtained by the Company. Ƒ
California applicants or employees only: Under section 1786.22 of the California Civil Code, you may view the file
maintained on you by the consumer reporting agency named above during normal business hours. You may also obtain a copy
of this file upon submitting proper identification and paying the costs of duplication services, by appearing at the Consumer
Reporting Agency identified above in person or by mail. You may also receive a summary of the file by telephone. The agency
is required to have personnel available to explain your file to you and the agency must explain to you any coded information
appearing in your file. If you appear in person, a person of your choice may accompany you, provided that this person furnishes
proper identification. Please check this box if you would like to receive a copy of an investigative consumer report or
consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy
under California law. Ƒ
Washington State applicants or employees only: You also have the right to request from the consumer reporting agency
a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

By signing below, I am also consenting to the sharing and transferring of information reported or learned about me to the Company’s
clients, affiliates and subsidiaries, now and at the time that I seek or maintain employment, assignment, or placement with or
through any of them.

Last Name: First Middle

Signature: Date:

Rev 7/13
 Criminal Conviction Questionnaire

It is essential that you answer the following questions about your background so that the Company can take into account
all factors. A prior criminal history will not necessarily disqualify you from employment with the Company; however, your
prior criminal history will be considered along with other factors such as the nature and severity of the offense, time that
has passed since the offense and/or the completion of the sentence and the nature of the position you are seeking. Your
answers to the following questions must be truthful, complete and accurate. If you do not answer the questions honestly
or you only provide part of the information, you will not be eligible for employment opportunities with the Company at the
present time or in the future. We recommend that you refer to your court records to complete the following questions. In
addition, you may want to contact your lawyer, the court, your probation/parole officer or seek other assistance in
completing this form.

(Print Name)
Name:_______________________________________________________ Last 4 SSN:___ ___ ___ ___
Last First Middle

1. HAVE YOU EVER BEEN CONVICTED OF, PLEAD GUILTY, NO CONTEST OR NOLO CONTENDERE TO A
FELONY OR MISDEMEANOR? *Please review all State Rules before answering*

Respond “No” if you have no convictions or if all convictions have been expunged, erased, sealed, annulled, dismissed
under a first offender’s law, pardoned or otherwise statutorily exonerated, eradicated or dismissed upon condition of
probation by the court, including sealed or expunged juvenile records of conviction or if the offense is a violation,
infraction or summary offense. Please note, convictions while you were a minor do not necessarily mean your conviction
is part of a sealed or expunged juvenile record or that you do not have to report it under applicable state law.
† Yes (please complete questions 2-5, signature required) † No (proceed to question 6, signature is required )

STATE RULES:

If you are currently a resident of or applying for work in California, answer NO if the conviction is: a) a
MISDEMEANOR conviction relating to Marijuana that is more than two (2) years prior to the date this questionnaire is
completed or b) relates to a referral to, and participation in, any pre-trial or post-trial diversion program.

If you are currently a resident of or applying for work in Connecticut please note that you are not required to
disclose the existence of any arrest, criminal charge or conviction, the records of which have been erased
pursuant to Connecticut General Statutes Sections 46b-146, 54-76o or 54-142a. Criminal records subject to erasure
pursuant to Connecticut General Statutes Sections 46b-146, 54-76o or 54-142a are records related to (a) determinations
of “delinquency” or that, as a child, you were a member of a family with service needs, (b) a ruling you are a “youthful
offender”, (c) a criminal charge that has been dismissed or nolled; (d) a finding you are not guilty for a criminal charge,
or (e) a conviction for which you have received an “absolute pardon”. Any person whose criminal records have been
erased pursuant to Connecticut General Statutes Sections 46b-146, 54-76o or 54-142a shall be deemed to never have
been arrested within the meaning of the general statutes with respect to the proceedings so erased and may so swear
under oath.

If you are currently a resident of the State of Massachusetts, answer NO if the conviction is a misdemeanor conviction
that: 1) is a sealed record, or 2) is a first conviction for drunkenness, simple assault, speeding, minor traffic violations,
affray or disturbances of the peace where the date of the conviction or the completion of any period of incarceration
resulting there from (whichever date is later) occurred five (5) or more years prior to the date of this questionnaire, unless
you were convicted of any other misdemeanor offense within the five years immediately preceding the date of this
questionnaire.

Adecco Group EOE M/F/D/V AOP32110 January 2014

Page 1 of 3
 Criminal Conviction Questionnaire

If you are currently a resident of or applying for work in Ohio, answer NO if the conviction is concerning minor
misdemeanor convictions for marijuana possession involving an amount less than 100 grams.

If you are currently a resident of or applying for work in Hawaii, please limit your response to 10 years unless
some period of incarceration resulting from a conviction took place within the last ten (10) years.

If you were convicted in New Jersey, when answering this question, please note that felonies refer to
crimes/indictments or criminal/indictable offenses and misdemeanors are generally referred to as disorderly persons
offenses

2. DETAILS OF CONVICTIONS:
If you answered “Yes”, please complete all fields below for each conviction. Please provide detailed information.
Responses such as “will discuss” are not acceptable. It is your responsibility to provide accurate and complete information.
Any uncertainty in answering the questions below should be resolved before submitting this questionnaire.

Conviction Felony or Date of Details of the offense. Sentence If you served Are you Provide date Age at the time
(Do not Misdemeanor Conviction If theft- related, specify or action time in jail, currently on Parole/Probation of conviction
abbreviate or (1.1) (Please the items involved, imposed what was your Parole/ was completed.
use penal note: this value of the items and by the date of Probation?
code date may the premises where court release?
numbers.) differ from offense took place
date of
arrest)
EXAMPLES:
March I stole an Iphone from 5 days in March 15, Yes, on Not complete.
Theft Misdemeanor 2013 a car that was parked jail. 1 2013 parole
in the parking lot year
where I worked. parole.
Iphone value was
$600.

3. EMPLOYMENT SINCE LAST CONVICTION:

Have you been employed for at least one year since your last conviction date or release date (whichever was later)?
† Yes † No

Adecco Group EOE M/F/D/V AOP32110 January 2014

Page 2 of 3
 Criminal Conviction Questionnaire

4. EVIDENCE OF REHABILITATION OR GOOD CONDUCT:

Do you have documentation of rehabilitation or good conduct that was obtained after your last conviction?
† Yes † No

If yes, you will be contacted by Adecco to provide a copy. Examples of such documentation may include:
x Transcripts, diplomas, certifications or letters from teachers evidencing training or education.
x References from an employer or job training program.
x Evidence of participation in counseling program or other workforce development or social service programs.
x Documentation of volunteer activities.

5. ADDITIONAL INFORMATION:
Do you have additional information that you would like Adecco to consider regarding your rehabilitation? † Yes † No
If yes, please add in the space provided below.

6. CERTIFICATION

I certify by signature below that the information provided on this form is true and complete. I understand that if I
fail to disclose a conviction or pending charge or provide false information, or if omissions or misrepresentations
are discovered, my application will be rejected and, if I am employed, my employment will be terminated. I
understand that I must inform the Company of any conviction and/or criminal charge that occurs while employed,
unless nondisclosure is protected by law. The transmission of this document by facsimile or electronic mail shall
constitute effective execution and delivery and may be used in lieu of the original for all purposes.

Signature: _______Date ______________________

Adecco Group EOE M/F/D/V AOP32110 January 2014

Page 3 of 3
 Mandatory Contact Notice

1) I understand and agree that, upon conclusion of each assignment, I must immediately contact my RPh on the
Go Health recruiter. I understand that such notification is for the purpose of determining eligibility and
availability of additional work assignments as well as other administrative purposes. If the recruiter who
initially placed me is not available, I can speak with another recruiter, leave a detailed voicemail message in my
recruiter’s mailbox, or email the detailed message to my recruiter or to the email address below. I accept that:
a) My failure to contact RPh on the Go as indicated above within two business days* of completion of
assignment may be considered a voluntary resignation and/or termination which may lead to the denial
and/or interruption of unemployment benefits.
b) It is my responsibility to inquire about any available assignment with RPh on the Go upon conclusion of my
assignment. If I fail to inquire about another assignment prior to filing for unemployment benefits, it may
lead to an interruption and/or denial of unemployment benefits.
c) If a suitable assignment is available with RPh on the Go upon conclusion of my assignment and I refuse an
offer of suitable work, it may lead to an interruption and/or denial of unemployment benefits.

2) I also understand and agree that I am required to contact my RPh on the Go recruiter at the telephone number
or email address listed below:
a) When my address, email or phone number changes;
b) If I experience any type of harassment or unlawful discrimination;
c) If I am not being provided a meal or rest break to which I am entitled;
d) If I have a complaint or dispute about my wages earned;
e) If I am exposed to blood and/or bodily fluid or injured while on assignment.

If you have any questions, please contact your RPh on the Go recruiter.

RPh on the Go Contact Information:

General Email Address: callinavailable@rphonthego.com

Main Telephone: 847-588-7170

I certify that I have read, fully understand, and accept all terms of the foregoing agreement:

Employee Name: ______________________________________________________________________________

Employee Signature: ___________________________________________________________________________

Date: _______________________________________________________________________________________

*Exceptions to the two business day notification period are listed below:
ƒ Iowa – Associates must contact RPh on the Go within three working days of completion of the temporary assignment.
ƒ Michigan – Associates must contact RPh on the Go within seven working days of completion of the temporary assignment.
 Dispute Resolution and Arbitration Agreement for Consultants/Associates
This Dispute Resolution and Arbitration Agreement for Consultants/Associates (“Dispute Resolution Agreement”) is entered
into as of this _____ day of ________________________ 20____, between RPh on the Go, its successors and assigns and its officers,
directors, employees, affiliates, subsidiaries and parent companies (collectively referred to as the “Company”), and
______________________________ (“Employee”).

Recitals
A. The Company desires to consider Employee for placement or the continuation of Employee on temporary work assignments
at Company’s client(s) (“Client(s)”);

B. Employee is desirous of such consideration or continued assignment; and

C. Employee and the Company desire to resolve any disputes concerning the terms, conditions or benefits of Employee’s
employment.

NOW THEREFORE, based on the above, and in consideration of the mutual covenants and conditions set forth herein, the
parties hereto agree as follows:

1. It is the Company’s goal that workplace disputes or claims be handled responsibly and on a prompt basis. Employee and the
Company are encouraged to take advantage of the procedures in the Company’s Open Door Policy and Code of Business Conduct and
solve problems and disputes informally, through dialog with Employee’s supervisor, manager or Human Resources representative.
Absent resolution through such process, the Company and Employee agree that any and all disputes, claims or controversies arising
out of or relating to this Agreement, the employment relationship between the parties, or the termination of the employment
relationship, shall be resolved by binding arbitration in accordance with the Employment Arbitration Rules of the American
Arbitration Association then in effect. These Rules can be obtained from the Human Resources Department or on line at
www.adr.org. The agreement to arbitrate includes any claims that the Company may have against Employee, or that Employee may
have against the Company or against any of its officers, directors, employees, agents, or parent, subsidiary, or affiliated entities, except
as set forth below. The arbitration shall take place in the county where Employee is or was last employed by the Company. The
Company and Employee agree that the aggrieved party must give written notice of any claim to the other party no later than the
expiration of the statute of limitations (deadline for filing) that the law sets forth for such claim. This Agreement shall be enforceable
under and subject to the Federal Arbitration Act, 9 U.S.C. Sec 1 et seq. and shall survive after the employment relationship terminates.
BY SIGNING THIS AGREEMENT, THE PARTIES HEREBY WAIVE THEIR RIGHT TO HAVE ANY DISPUTE, CLAIM
OR CONTROVERSY DECIDED BY A JUDGE OR JURY IN A COURT.

2. Except as it otherwise provides, this Dispute Resolution Agreement also applies, without limitation, to disputes regarding the
employment relationship, trade secrets, unfair competition, compensation, breaks and rest periods, termination, or harassment and
claims arising under the Uniform Trade Secrets Act, Civil Rights Act of 1964, Americans With Disabilities Act, Age Discrimination in
Employment Act, Family Medical Leave Act, Fair Labor Standards Act, Employee Retirement Income Security Act, Genetic
Information Non-Discrimination Act, and state statutes, if any, addressing the same or similar subject matters, and all other state
statutory and common law claims.

3. The arbitration requirement does not apply to (i) claims for workers compensation, state disability insurance and
unemployment insurance benefits; (ii) claims for employee benefits under any benefit plan sponsored by the Company and covered by
the Employee Retirement Income Security Act of 1974 or funded by insurance; however, this Dispute Resolution Agreement does
apply to claims for breach of fiduciary duty, for penalties, or alleging any other violation of the Employment Retirement Income
Security Act of 1974, as amended, even if such claim is combined with a claim for benefits; and (iii) disputes that may not be subject
to predispute arbitration agreements as provided by the Dodd-Frank Wall Street Reform and Consumer Protection Act (Public Law
111-203).

4. Regardless of any other terms of this Dispute Resolution Agreement, claims may be brought before an administrative
agency if applicable law permits access to such an agency notwithstanding the existence of an agreement to arbitrate. Such
administrative claims may include without limitation claims or charges brought before the Equal Employment Opportunity
Commission (www.eeoc.gov), the U.S. Department of Labor (www.dol.gov), the National Labor Relations Board
(www.nlrb.gov), or the Office of Federal Contract Compliance Programs (www.dol.gov/esa/ofccp). Nothing in this Dispute Resolution

Version 01/17/12
Agreement shall be deemed to preclude or excuse a party from bringing an administrative claim before any agency in order to fulfill
the party's obligation to exhaust administrative remedies before making a claim in arbitration.
5. Although Employee will not be retaliated against, disciplined or threatened with discipline as a result of his or her exercising
his or her rights under Section 7 of the National Labor Relations Act by the filing of or participation in a class, collective or
representative action in any forum, the Company may lawfully seek enforcement of this Dispute Resolution Agreement including the
following class, collective and/or representative action waivers under the Federal Arbitration Act and seek dismissal of such class,
collective or representative actions or claims.

6. Employee or the Company may apply to a court of competent jurisdiction for temporary or preliminary injunctive relief in
connection with an arbitrable controversy, but only upon the ground that the award to which that party may be entitled may be
rendered ineffectual without such provisional relief.

7. BY SIGNING THIS AGREEMENT, THE PARTIES AGREE THAT EACH MAY BRING CLAIMS AGAINST THE
OTHER ONLY IN THEIR INDIVIDUAL CAPACITY, AND NOT AS A PLAINTIFF OR CLASS MEMBER IN ANY
PURPORTED CLASS AND/OR COLLECTIVE PROCEEDING.

8. FURTHERMORE, BY SIGNING THIS AGREEMENT, THE PARTIES AGREE THAT EACH MAY BRING
CLAIMS AGAINST THE OTHER ONLY IN THEIR INDIVIDUAL CAPACITY AND NOT IN ANY REPRESENATATIVE
PROCEEDING UNDER ANY PRIVATE ATTORNEY GENERAL STATUTE (“PAGA CLAIM”), UNLESS APPLICABLE
LAW REQUIRES OTHERWISE. IF THE PRECEDING SENTENCE IS DETERMINED TO BE UNENFORCEABLE,
THEN THE PAGA CLAIM SHALL BE LITIGATED IN A CIVIL COURT OF COMPETENT JURISDICTION AND ALL
REMAINING CLAIMS WILL PROCEED IN ARBITRATION.

9. Within 30 days after signing this Agreement, Employee may submit a form stating that Employee wishes to opt out and not
be subject to the Dispute Resolution Agreement. Employee must submit a signed and dated statement on a "Dispute Resolution and
Arbitration Agreement for Consultants/Associates Opt Out Form" ("Form") that can be obtained from the Company Human Resources
Department at 847-588-7493 or tina.musgrove@soliant.com. An Employee who opts out as provided in this paragraph will not be
subject to any adverse employment action as a consequence of that decision and may pursue available legal remedies without regard to
the Dispute Resolution Agreement. Should Employee not opt out of the Dispute Resolution Agreement in a timely manner, Employee
and the Company will be deemed to have mutually accepted the terms of the Dispute Resolution Agreement.

10. It is understood and agreed by the parties that a Client and its affiliates are intended to be third party beneficiaries to this
Dispute Resolution Agreement. Although the Client and its affiliates are not the Employee’s employer, any disputes that may be
asserted against Client or its affiliates due to Employee’s temporary work assignment at Client shall be resolved pursuant to this
Dispute Resolution Agreement in the same manner as claims made against the Company.

11. An Employee has the right to consult with counsel of the Employee's choice concerning this Dispute Resolution Agreement.
Employee has read this Dispute Resolution Agreement carefully, fully understands the meaning of its terms and is signing it
knowingly and voluntarily.

12. It is against Company policy for any Employee to be subject to retaliation if he or she exercises his or her right to assert
claims under this Dispute Resolution Agreement. If any Employee believes that he or she has been retaliated against by anyone at the
Company, the Employee should immediately report this to the Company Human Resources Department.

13. The Company may change or modify the terms of the Dispute Resolution Agreement at any time with reasonable prior notice
to Employee. It is understood that future changes will supersede or eliminate, in whole or in part, the terms of the Dispute Resolution
Agreement. Current versions of the Dispute Resolution Agreement will be posted by the Company on the Company’s internet site or
such other location(s) designated by the Company.

14. If any provision(s) of this Dispute Resolution Agreement is declared overbroad, invalid or unenforceable such provision(s)
shall be severed from this Dispute Resolution Agreement and, the remaining provisions of this Dispute Resolution Agreement shall
remain in full force and effect and shall be construed in a fashion which gives meaning to all of the other terms of this Dispute
Resolution Agreement.

IN WITNESS WHEREOF, the parties have voluntarily and knowingly executed this Dispute Resolution Agreement on the day and
year first written above.

EMPLOYEE RPH ON THE GO

____________________________________________ ____________________________________________