* Are you legally authorized to work in the United States under the immigration laws of the United States?:

* Have you ever applied for a position or were previously employed by this Company?:

If you answered yes to the previous question please provide details:

* Do you understand and can you perform the essential functions of this position with or without reasonable accommodations?:

* Have you ever been excluded from the Medicare, Medicaid and/or other federal or state health care program?:

If you answered yes to the previous question please provide details:

* Have you ever been found guilty by a court of law of abusing, neglecting, mistreating, or misappropriating the property of an individual in a healthcare setting?:

If you answered yes to the previous question please provide details:

* Have you ever been disqualified by any federal, state, county or local authority from working with older adults or children?:

If you answered yes to the previous question please provide details:

* Have you ever been convicted of a felony, misdemeanor or other criminal offense (including a civil forfeiture)?:

If you answered yes to the previous question please describe in full, including date(s): (Conviction will not automatically disqualify an applicant from consideration for a position. The circumstances of the crime will be considered as it relates to the job, as required by applicable state law, or if the applicant is not bondable for a job requiring bonding.)

* In the past three years, have you ever knowingly used any narcotics, amphetamines or barbiturates, other than those prescribed to you by a physician?:

If you answered yes to the previous question please provide details: (Prior drug use will not disqualify you from consideration if you have been rehabilitated and are not currently using illegal drugs.)

*Has any medical professional licensing board in any state ever taken any disciplinary or corrective action of any nature against you?:

If you answered yes to the previous question please provide a description including the following information:

• The licenses and/or registrations that were suspended, revoked or otherwise affected;
• The sanctions imposed including any civil penalties;
• A brief description of the basis for the disciplinary action or corrective measure;
• The state where it occurred;
• The name of the licensing board; and
• The effective date of the action(s)

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Reference #1

Reference #2

Reference #3

Education

High School

Technical/Business

College/University

Post Graduate

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* Describe your duties:

* Reason for leaving:

Employer #2

* Describe your duties:

* Reason for leaving:

Employer #3

Describe your duties:

Reason for leaving:

Required

*Share what you have done in the past six (6) months that has enhanced your professional development, and explain how that will help you to successfully fulfill the requirements of the position for which you are applying:

Review