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:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Phone:
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Area Code
Phone Number
E-mail:
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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:
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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.
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"I Do."
I acknowledge that I have received and agree to NVP's Employment Handbook Policies
"I Agree"
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.
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"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."
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