Applicants Name

Job Applying For

Address

City

State

ZIP

Home Phone

Cell Phone

Your Email Address

Major Cross Streets

Are you legally eligible to work in the United States?

Please list three (3) personal references that are not related to you

Reference 1

Name

Phone

Relationship

Years Known

Address

Reference 2

Name

Phone

Relationship

Years Known

Address

Reference 3

Name

Phone

Relationship

Years Known

Address

7. Do you possess a valid driver's license?

State of Issue & License Number

8. Has your driver’s license even been suspended or revoked?

9. Have you ever been convicted of a felony?

If yes, please explain

10. Have you ever had a license to provide health care revoked, limited, modified,
or suspended?

11. Have you ever had any disciplinary action taken against your license to provide

health care?

12. Have you ever had any criminal conviction relating to:

a) Any federal health care program including Medicare and Medicaid?

b) Patient neglect or abuse?

c) Healthcare fraud?

d) Use of a controlled substance?

e) Fraud, theft, embezzelment?

f) Breach of fiduciary responsibility or other financial misconduct?

g) Obstruction to a health care investigation?

PLEASE READ
The facts set forth in my volunteer application are true and complete. I understand that if accepted in a volunteer role, false statements or omissions on this application will usually result in revocation of my volunteer status.

Permission is herby given to the Company to investigate previous employment, educational background and references. I release the Company and former employers from any liability resulting from any lawful information provided which may result in termination of my volunteer status.

I understand that the Company has a policy requiring that a background check be completed on all volunteers, and will be done upon completion of the Volunteer Training Program at no cost to me. I agree to provide any additional information necessary to complete the background check.

I understand that the Company has a policy prohibiting conflicts of interest or improper use of proprietary information which prohibits any release or use of Company property that would interfere with the business interests or operations of the Company. I understand that my volunteer status may be terminated at any time by either the Company or myself with or without cause.