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PERSONAL INFORMATION





Attach your documnets if any:

EDUCATIONAL BACKGROUND












SPECIAL LICENSES, CERTIFICATIONS OR REGISTRATION















GENERAL INFORMATION
Are you legally authorized to work in the USA?YesNo
(If you became an employee of NCCP, you will be required to provided documentation proving your eligibility to work in the USA)

Have you ever been convicted of a felony or misdemeanor crime?YesNo
(This does not apply if the conviction has been expunged, is contained in a sealed record, or was a juvenile conviction.)

A criminal conviction will not necessarily bar you from employment. We will consider the nature of the crime, the time that has expired since its
occurrence and any rehabilitation you have undergone.

If yes, state the basis for each conviction and the date of the conviction:

Are you able to perform the tasks according to the job description without accommodation?YesNo

If an accommodation is needed, how would perform the task and with what accommodation?

How did you hear about NCCP? NewspaperTrade PublicationJob Fair/Open HouseEmployment Agency

NCCP employee (name): Yes
Work location: Yes

WORK EXPERIENCE - Please complete all appropriate items, even if you have already provided us with a resume.








May we Contact?:YesNo









May we Contact?:YesNo









May we Contact?:YesNo

Please list any other work related information you think would be helpful to us in considering you for employment, such as foreign language competency, additional work experience, volunteer work, activities, accomplishments, publications, patents, thesis, etc.

REFERENCES - Please list three individuals with whom you have worked who were in a position to evaluate your performance.

I certify that the information in this application is accurate, current and complete. I understand that misstatements or omissions may result in disqualification from further consideration or termination of employment. I agree that, if hired, I may be discharged if NCCP learns of any falsification or consideration not only for this position, but future positions, as well. (NOTE: You will not automatically be excluded from consideration if you have been convicted of a crime. Your suitability for the position sought will be evaluated based upon the totality of circumstances such as the nature of the crime, the recency of the conviction, the type of work involved, etc.)

I understand and agree that all information concerning patients and their families is strictly confidential. I am not permitted to disclose any financial, medical or personal information related to any patient or family member to fellow employees, company administrative staff or individuals, except my supervisor at NCCP.

I authorize NCCP to investigate my employment history, credentials, license verification and to obtain any relevant information, including a criminal background check needed to make an employment decision. I authorize NCCP to disclose this application along with any information about me obtained through reference checks or during the course of the interview process for state, federal, contractual or accreditation audit purposes. I also authorize NCCP to disclose any of my performance appraisals, disciplinary records or skills tests for the same purposes as above. I release NCCP and any individual or entity providing information to NCCP from all liability for any damage from the disclosure of this information.

I also understand and agree that passing a medical examination (which is my responsibility) and/or medical screening may be required. Ifmedical restrictions cannot be reasonably accommodated, I may not be hired, if hired, I may be terminated.

I understand and agree that I may be subject to pre-employment drug testing and/or alcohol testing, random testing, as well as testing where reasonable suspicion or improper usage has occurred, or where warranted by an on-the-job injury, circumstance, workplace conditions or contractual requirements.

I understand and agree that nothing contained in this employment application or in the granting of an interview creates an employment contract between NCCP and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me. If an employment relationship is established, I understand that my employment will be terminable “at will;” that is, I will have the right to terminate my employment at any time and that NCCP retains the same right to terminate my employment at any time.

I understand that should I become employed by NCCP, my work assignments, schedules and/or work locations are subject to change according to the needs of the business and the clients of NCCP.

I understand that NCCP is committed to promoting safety and high standards of employee performance, productivity and reliability. In order to achieve this, I may be subjected to a drug test prior to being hired to assure NCCP I do not currently have narcotics, sedatives, stimulants or other controlled substances and/or mood-altering substances in my body. I understand if I have any such substance in my body at the time of the drug test, NCCP will not hire me.

I understand that NCCP reserves the right to add to, change and/or delete their policies, procedures, work rules and benefits at any time and that no one in NCCP has the authority to enter into any agreement for any particular period of time, or contrary to the above terms, unless that agreement is set forth in writing and signed by an authorized representative of NCCP.

I accepts terms and conditions: Yes
Date:

Pursuant to Title VII of the Civil Rights Act of 1965 (42 U.S.C., §20000d et seq.) and 45 C.F.F. Part 80, §504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. §6101 et seq.), VHCS adheres to an equal opportunity policy for all persons seeking admission as clients or seeking employment and for all persons employed by NCCP. NCCP offers equal employment and advancement opportunities to qualified individuals without regard to race, color, religion, sex, age, national origin, marital status, disability or any other category protected by any applicable local, state, federal law, ordinance or regulation.