Form

Position Application: NVPUSA does not discriminate against any person on the basis of race, religion, color, gender, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law.
Full Name:
First Name Last Name

Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone: *
- Area Code Phone Number
E-mail: *
Position Applying for:
Highest Level of Education. If college, what degree of study do you hold? *
Describe days and hours of availability: *
Are you willing to work evenings, weekends, and travel when required?

Yes No
Attestation
Do you require special accommodations required by ADA? Type “No” if not applicable: *
Felony or Misdemeanor Convictions: Please describe in full detail. Does not disqualify you. Type "NA" if no offence occurred. *
Attest to not using illegal substances

Yes No
Attest that you do not maintain a history of loss or limitation of privileges or disciplinary actions that may lead to current or past adverse actions

Yes No
Attest that you do not present a risk management concern, including: malpractice actions, insurance cancellations, Medicare/Medicaid sanctions, and ethical violations.

Yes No
End of Attestations
List any and all technical skills: *
Ideal Start Date: *
In what year(s) did the offense take place. Type "NA" if no offence occurred: *
Professional Photo. If hired, this will be attached to your company id:
Copy of Drivers License: *
Resume: One Page Maximum: *
Transcripts: College or Highschools or GED: Must have a copy of the graduation certificate
Social Secuity Number: *
State Practicing License Number (If Applicable) For clinicians:
NPI # (If Applicable):
Medicaid Provider Number (If applicable):
Medicare Provider Number (if applicable):
Copy of W-2 (Please refer to IRS guidelines
Copy of W-9 (Please refer to IRS guidelines) (If applicable):
Copy of I-9 (Please refer to IRS guidelines) (If applicable):
Copy of Social Security Card or Passport
DEA Number (If applicable)
Copy of Florida Certification Board Licenses or Certificates where applicable
Copy of General Liability or Malpractice Insurance (If applicable)
Three Letters of Recommendation (Copy in PDF format) (Not required for the FEMA position).
List Three References: Name and Phone Number. Non-Family: *
I verify that the statements I have made here on this application are true and complete. I understand that if I am hired, any false or incomplete information in this application will provide grounds for discharge. *

"I Do."
I agree to provide and allow NVPUSA authorization to conduct reference checks and contact former employers: *

"I Do."
Nothing on this application is intended to create or imply a contractual relationship. If hired, the applicant understands that employment is at-will and may be terminated by the applicant or the company at any time with or without reason. *

"I Understand."
In consideration for my employment, I agree to abide by the rules and regulation of the company, which rules may be changed, withdrawn, added or interpreted any any time, at the company's sole option and without prior notice to me. *

"I Agree."
Should be Empty:

Position Application: NVPUSA does not discriminate against any person on the basis of race, religion, color, gender, sexual orientation, age, national origin, disability, veteran status, or any other status or condition protected by law.

Attestation

End of Attestations