EMPLOYMENT » My Positive Transformation, PLLC

    Last Name*

    First Name*

    Middle Initial

    Date of Birth*

    Street Address*

    City*

    State*

    Zip Code*

    Email Address*

    Phone Number*

    Emergency Contact Name*

    Emergency Contact Phone*

    Today's Date*

    Contract Position Desired

    Hours desired

    Start Date Desired

    Have you ever applied to work or contract with My Positive Transformation before? If yes, when?

    Gender *

    Do you have any friends or relatives employed or contracting for My Positive
    Transformation? If yes, please list their name and your relationship to them.

    Historical Information

    Yes

    No

    Are you at least 18 years old?

    Can you present evidence of citizenship and legal right to work in the
    United States?

    Have you ever been convicted of a criminal offense (felony or misdemeanor)?* If yes, please list the nature of the conviction, when and where convicted you; the disposition of the case.

    Are you now, or have you ever been under investigation, suspended, or excluded from participation in the Medicare, Medicaid, or other state and/ or federal programs?* If yes, please describe the nature of the incident, when and where the incident took place, and the outcome.

    Taxpayer Identification Number:

    Website:

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    Insurance Document





    Company & Address

    Dates Employed

    Position Held

    Supervisor

    Reason for Leaving

    May we contact any of your previous employers or contracts for a reference?

    If not, please indicate which
    employer should not be contacted.

    Additional Information

    Do you have prior experience, training, qualifications or skills which you feel relate specifically to this contract?

    Have you ever had a professional license or certification revoked? If yes, please list details.

    Reference 1:

    Reference 2:

    Reference 3:

    Please Read Carefully, Initial Each Paragraph and Sign Below.

    Initials

    Statement

    1.

    I certify under penalty of perjury that I have not knowingly withheld any information that might adversely affect my chances for contract and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned, have personally completed this document. I understand that any omission or misstatement of material fact on this application or on any document used to secure a contract position shall be grounds for rejection of this application or for immediate discharge of contract, regardless of the time elapsed before discovery.

    2.

    I acknowledge that it is my responsibility to notify My Positive Transformation in writing if an investigation begins, or if I become suspended or excluded from participation in Medicare, Medicaid, or any state/federal programs.

    3.

    I authorize My Positive Transformation to investigate my references, work record, education and other matters related to my suitability for contractual status, and further, authorize the references I have listed to disclose information related to my work records. I release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands, or liabilities arising out of or in any way related to such investigation and disclosure.

    4.

    I understand that any offer of contractual status may be conditioned upon satisfactorily completion of a criminal background screen. I agree to sign a release of information authorization form to authorize this screen, should My Positive Transformation condition my offer upon successful completion of such an examination or screening.

    5.

    I will inform My Positive Transformation in writing if I am convicted of a felony or serious misdemeanor that could affect the conditions of my contract, or if I come under investigation for alleged fraud, waste or abuse or am suspended or excluded from participation in the Medicare/ Medicaid programs or any state/ federal program.