Has your license or certification ever been investigated or suspended?

Have you ever been convicted of a crime other than a minor traffic violation?

Have you ever been named as a defendant in a professional liability action?

Are you either a U.S. Citizen or can you submit verification of your legal right to work in the U.S.?

I attest that I am the applicant and the information provided in this application is complete and accurate, to the best of my knowledge. Providing incomplete or inaccurate information may result in disqualification from the program, and may be a violation of state law(s) that could result in civil penalties. The Company is authorized to obtain information from my current and previous employers, and to release information in support of my application (application, references, background search results, etc.) to the Company's client institutions. The Company may also share information regarding my employment with its affiliates and appropriate governmental or licensing entities. I consent to receiving employment opportunity-related information at all phone numbers or email addresses that I provide. I understand that the Company, certain states and/or Client institutions may require criminal background checks, and I consent to such checks. Prior to conducting any background checks that qualify as consumer or investigative consumer reports, I will be provided, and will return, separate disclosure and acknowledgement forms as required by the Company.