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Last Name First Name Middle Name Today's Date

MedSearch Corp.Medical Placement Service

Since 1936!Southdale Medical Center

Suite 177 · 6545 France Avenue South. Edina, Minnesota 55435Phone: 952/926-6584 · Toll Free 1-800-458-4965 · Fax: 952/926-7584

MedSearch Corp. is an Equal Opportunity Search Firm

Instructions:1. Please print.2. Please inform us if assistance/accommodation is needed in completing the application, or during

any part of the application process.3. Please do not use resume in place of information on application.4. Include any relevant military experience and unpaid work experience, if any.5. Please make sure to read and sign page 4.

Employment Application

PERSONAL INFORMATIONLast Name First Name Middle Name Social Security Number

Street Address Apt. # Home Phone with Area Code

City County State Zip Office Phone with Area Code Message Phone with Area Code

o Full-time Schedule Preference

o Part-time o Days o Nights

Hours per week o Evenings o Weekends

Position Desired Date Available Salary Desired

First Choice

Name and location of college or university egree Received?

Indicate Degree:

Courses/Major Honors

Name and location of college or university egree Received? 0 Yes 0 No I GPA I Courses/Major

Indicate Degree:

Honors

BusinessfTechnicalNocational/Correspondence, etc. Certificate/degree or # of credits Subject

Describe any other specialized training or qualifications relating to this position (such as seminars. military. professional affiliations. certificates, awards. internships, externships)

EDUCATION continued ,~'., 'tProfessional licenses/certificates/registrations (include numbers) Expiration date:

Expirationdate:

Expiration date:

BUSINESS SKILLS :., rw .List professional, technical or clerical skills that you would bring to the position for which you areapplying (e.g., accounting, computer hardware, software, programming languages, etc.):

List office equipment you can operate (e.g., calculator, wordprocessor, personal computer, etc.):

BUSINESS REFERENCES Please list business or work related references and their relationship to youName Business Relationship Area CodefTelephone Number

1.

2.

3.

2

EMPLOYMENT HISTORY '...1. Dates of employment (current or most recent position) Title of position

From Mo./Yr. To Mo./Yr.Name of employing firm Type of business Area Code/Phone

Address May we contact forDYes o No o Full-time o Part-timereference?

City State Zip Salary:

Starting $ Rnal$

Supervisor (Name and Area CodelPhone Number) Base Pay Incentives$ $

Description of duties performed, skills, accomplishments

Reason for leaving

2. Dates of employment Title of position

From Mo./Yr. ToMo./Yr.

Name of employing firm Type of business Area Code/Phone

Address May we contact forDYes o No o Full-time o Part-timereference?

City State Zip Salary:Starting $ Final $

Supervisor (Name and Area Code/Phone Number) Base Pay Incentives$ $

Description of duties performed, skills, accomplishments

Reason for leaving

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3

3. Dates of employment Title of positionFrom Mo.tYr. ToMo.tYr.

Name of employing firm Type of business Area Code/Phone

Address May we contact forDYes o No o Full-time o Part-timereference?

City State Zip Salary:Starting $ Final $

Supervisor (Name and Area Code/Phone Number) Base Pay Incentives$ $

Description of duties performed. skills. accomplishments

Reason for leaving

4. Dates of employment Title of position

From Mo.tYr. ToMo.tYr.

Name of employing firm Type of business Area Code/Phone

Address May we contact forreference? DYes o No o Full-time o Part-time

City State Zip Salary:

Starting $ Final $

Supervisor (Name and Area Code/Phone Number) Base Pay Incentives$ $

Description of duties performed. skills, accomplishments

Reason for leaving

5. Dates of employment Title of position

From Mo.tYr. To Mo.tYr.

Name of employing firm Type of business Area Code/Phone

Address May we contact forDYes o No o Full-time o Part-timereference?

City State Zip Salary:

Starting $ Final $

Supervisor (Name and Area Code/Phone Number) Base Pay Incentives$ $

Description of duties performed. skills. accomplishments

Reason for leaving

If you have been unemployed for a period of three consecutive months or more within the past seven years, please provide the dates of unemployment and anexplanation below:

List any professional activities, experiences. achievements, or other special skills not mentioned elsewhere that relate to the position(s) for which you are applying:

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LEGAL CONTRACT. READ AND UNDERSTANDALL AGREEMENTSAND CONTRACTSARE SUBJECTTO THE RULESOF THE DEPARTMENTOF LABOR

& INDUSTRYAND THE LAWSOF THE STATEOF MINNESOTA.

In no instance will any individual candidate who is identified, appraised or recommended by MedSearch Corp. for employ-ment become liable in whole or in part to pay a fee of any kind, directly or indirectly, on account of any service performedby MedSearch Corp.All information given to me by MedSearch Corp. is to be held confidential and is given to me only for myexclusive use and benefit.I agree to notify MedSearch Corp. promptly upon the acceptance of a position and report the results of all interviews.

I HAVE READ AND UNDERSTAND THEABOVE CONTRACT. I HAVE DISCUSSED THISCONTRACT WITH A REPRESENTATIVE OFTHE AGENCY AND HAVE RECEIVED ADUPLICATE.

Dated

AcceptedConsultant Signature of Applicant

AUTHORIZATION AND ACKNOWLEDGMENTMedSearch Corp. is committed to equal employment opportunity for all applicants without regard to race, color, creed,religion, gender, age, marital status, national origin, disability, sexual orientation, or any other characteristic protectedunder federal, state, or local law.

I hereby acknowledge the filing of my employment application with MedSearch Corp. to assist me in securing employment.The information I have provided in this application (including all attachments) is true and correct. I authorize MedSearchCorp. to conduct an inquiry into the information contained in this application. I authorize my current and former employers,educational institutions, and all licensing, registering and certifying organizations to provide information about me. I herebyrelease all employers, educational institutions, and other individuals or entities which may provide information about me inconnection with this application from all liability for issuing such information. I further understand that this information willbe shared with all appropriate employers who have listed job openings with MedSearch Corp. I hereby waive any privilegeI may have to such information. I also understand that my employment is conditioned upon acceptable references andbackground checks (for certain positions, employment is also conditioned upon drug testing). I hereby acknowledge thatI have read and received a copy of this statement.

Today's DateSignature of Applicant

CONSULTANT'S NOTES

4

LEGAL CONTRACT. READ AND UNDERSTANDALL AGREEMENTSAND CONTRACTSARE SUBJECTTO THE RULESOF THE DEPARTMENTOF LABOR

& INDUSTRYAND THE LAWSOF THE STATEOF MINNESOTA.

In no instance will any individual candidate who is identified, appraised or recommended by MedSearch Corp. for employ-ment become liable in whole or in part to pay a fee of any kind, directly or indirectly, on account of any service performedby MedSearch Corp.All information given to me by MedSearch Corp. is to be held confidential and is given to me only for myexclusive use and benefit.I agree to notify MedSearch Corp. promptly upon the acceptance of a position and report the results of all interviews.

I HAVE READ AND UNDERSTAND THEABOVE CONTRACT. I HAVE DISCUSSED THISCONTRACT WITH A REPRESENTATIVE OFTHE AGENCY AND HAVE RECEIVED ADUPLICATE.

Dated

AcceptedConsultant Signature of Applicant

AUTHORIZATION AND ACKNOWLEDGMENTMedSearch Corp. is committed to equal employment opportunity for all applicants without regard to race, color, creed,religion, gender, age, marital status, national origin, disability, sexual orientation, or any other characteristic protectedunder federal, state, or local law.

I hereby acknowledge the filing of my employment application with MedSearch Corp. to assist me in securing employment.The information I have provided in this application (including all attachments) is true and correct. I authorize MedSearchCorp. to conduct an inquiry into the information contained in this application. I authorize my current and former employers,educational institutions,and all licensing, registering and certifying organizations to provide information about me. I herebyrelease all employers, educational institutions, and other individuals or entities which may provide information about me inconnection with this application from all liability for issuing such information. I further understand that this information willbe shared with all appropriate employers who have listed job openings with MedSearch Corp. I hereby waive any privilegeI may have to such information. I also understand that my employment is conditioned upon acceptable references andbackground checks (for certain positions, employment is also conditioned upon drug testing). I hereby acknowledge thatI have read and received a copy of this statement.

Signature of Applicant Today's Date

CONSULTANT'S NOTES

4

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Disclosure and Authority to Release Information

I understand that in processing my application with MedSearch Corp, an investigativeconsumer report may be conducted. FCRA § 606. (a) (1) disclosure requirements; Any suchbackground check report may contain information bearing on my character, general reputation,personal characteristics, mode of living and credit standing. Information may include, but is notlimited to; employment history, education, criminal records, credit history, motor vehicle records,personal references, and any data provided on this application, or during the interview process.

If currently employed: My current employer may be contacted 0 Yes o No

I authorize the appropriate individuals, companies, institutions or agencies to release information,and I release them from any liability as a result of such inquiries or disclosures.

I further understand and waive my right of privacy in this investigation and release and holdharmless MedSearch Corp, and its agent Verified Credentials, Inc., from any liability.

An investigative consumer report may be generated summarizing this information. I have a rightunder the "Fair Credit Reporting Act" and state law to obtain a copy of this report by providingproper identification and directing a written request to Verified Credentials, Inc., 20890 KenbridgeCourt, Lakeville, MN 55044. 1-800-473-4934.

If employed in CA, MN, or OK; I would like a copy of my report. 0 Yes o No

I hereby certify that all the statements and answers set forth on the application form and/or myresume are true and complete to the best of my knowledge, and I understand that if anystatements and/or answers are found false or the information has been omitted, such falsestatements or omissions may be cause for rejection or termination of my employment orapplication.

Legal Last Name Legal First Name Legal Middle Name

Street Address

City State Zip Code

Please list any additional addresses you have lived, worked and attended schools in during the past 7 years:

City State City State

City State City State

Other Name(s) Used and Date(s) Changed:

DriversLicenseNumber State Issued ExpirationDate Dateof Birth(To be usedfor BackgroundInformationID only)

I AUTHORIZEA PHOTOCOPYOFTHIS RELEASETO BEACCEPTEDWITHTHE SAMEAUTHORITYAS THEORIGINALAND IF EMPLOYEDBYTHE ABOVENAMEDCOMPANYTHIS RELEASEWILLREMAININ EFFECTTHROUGHOUTSUCHEMPLOYMENT.

Signature Social Security Number Date