Intergovernment Affairs Internship Form

School

Name

First NameMiddle NameLast Name

Previous Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

If you have resided at your present address listed above for less than three years, indicate your previous address(es) here

Phone number

Area CodePhone Number

Email

example@example.com

Date of birth

Date

Highest level of education

Do you speak multiple languages?

YesNo

If yes, please list languages below

Emergency contact

First NameLast Name

Relationship

Emergency contact phone number

Area CodePhone Number

Resume and cover letter

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Have you been convicted of a misdemeanor or felony? Answer “NO” if: (a) you have never been convicted of a misdemeanor or felony; (b) the misdemeanor or felony was sealed, expunged, or reversed on appeal; (c) was for a violation, infraction, or other petty offense such as “disorderly conduct;” (d) resulted in a youthful offender or juvenile delinquency finding; or (e) if you withdrew your plea after completing a court program and were not convicted of a misdemeanor or felony.

YesNo

Supporting documents

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U.S. Department of Health and Human Services (HHS)Office of Inspector General (OIG) List of Excluded Individuals or Entities(LEIE)?

YesNo

NYS Office of Medicaid Inspector General (OMIG) List of Restricted, Terminated or Excluded Individuals or Entities?

YesNo

U.S. General Services Administration (GSA) System for Award Management (SAM) Excluded Parties List?

YesNo

Office of Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons List (SDN) or any other sanction list in the US Treasury Department's Consolidated Sanctions List?

YesNo

Office of Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons List (SDN) or any other sanction list in the US Treasury Department's Consolidated Sanctions List?

YesNo

I understand and agree that submitting this application form does not automatically guarantee a position at NYC Health + Hospitals. I am aware there may be qualifications I must meet, including orientation, medical clearance, drug test and background investigation. By submitting this form, I attest that the information I have provided on the form is true, accurate, and NOT provided by a third party. In furtherance of the background investigation, I consent to and authorize the disclosure of all information NYC Health + Hospitals deems relevant to the evaluation of my eligibility to hold a position of public trust. I, therefore, authorize the disclosure of such information to NYC Health + Hospitals, including but not limited to, files and records maintained by former and current employers, hospitals, clinics and the U.S. Veterans Administration, by educational institutions, governmental bodies, professional associations, and by investigative, disciplinary, judicial or grievance bodies. Furthermore, as may be required under the Privacy Act of 1974, 5 United States Code Section 552a, and the Freedom of Information Act, 5 United States Code Section 552, I hereby give my consent to inquiries concerning me by NYC Health + Hospitals to any Federal agency or public or private entity, and to the disclosure to NYC Health + Hospitals by such Federal agency or public or private entity of any information the agency or entity may have pertaining to me, with the exception of any material which is specifically exempt from disclosure by a Federal statute other than the Privacy Act of 1974 or the Freedom of Information Act. I waive any privilege of confidentiality with respect to the release of any such information to the NYC Health + Hospitals. A photocopy of this authorization shall be considered effective and valid, as the original, which shall remain on file at the facility/business unit of the NYC Health + Hospitals, for this and any future reports or updates that may be requested. Further information may be made available upon written request within a reasonable period of time. To continue this form, click "I agree" and place your signature at the bottom of this form.

YesNo

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Community Affairs

APPLICANT INFORMATION

CONVICTION RECORD

EXCLUDED PROVIDER LIST CERTIFICATION