List employment history, starting with the most recent employer.

Professional Reference Check

Please list your professional references.

Emergency Contact Information

Please add 2 emergency contacts and medical contact information below.

Medical Information

Vaccination Information

In order to be considered for employment you must fill out the USCIS Form I-9.

1. Go to this link https://www.uscis.gov/sites/default/files/document/forms/i-9.pdf  (this link will open in a new window)
2. Fill out the form online. (or print and fill out)
3. Download the completed PDF file. (or scan as PDF your completed form)
4. Attach the PDF file here –>

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL.

I,

authorize complete investigation of all statements contained herein and hereby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

This application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether or not applications are being accepted at that time.

I authorize PartnerCare Health, LLC to use all state-approved portals for my background check and OIG exclusion list.