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Professional / Personal References (Must Complete)

Persons who can furnish information about job performance or personal information about you.

General Questions

1) Date Available: *

2) Desired Salary: *

3) Are you a citizen of the United States? *

4) If No was your answer to the last question, are you authorized to work in the U.S.? *

5) Have you ever worked for this company? If yes, when? *

6) Have you ever been convicted of a felony? If yes, explain: *

7) (Only answer the following if you have served Military Service) Branch: (Optional)

8) (Only answer the following if you have served Military Service) Rank at Discharge: (Optional)

9) (Only answer the following if you have served Military Service) Type of Discharge? If other than honorable, explain: (Optional)

10) (Only answer the following if you have served Military Service) Term of service: (Optional)

11) I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. *

OIG/LEIE Background Checks

POLICY

We comply with licensure requirements regarding criminal history record checks, the OIG for employees, subcontractors, and volunteers.

PROCEDURE

1. Inform the individual who applies for employment that the agency is required to conduct a background check
2. Review the LEIE maintained by the United States Department of Health and Human Services, Office of Inspector General, and the LEIE maintained by the HHS Office of Inspector General:
   • before hiring an applicant for employment or contracting with a potential subcontractor; and
   • at least monthly, for each employee and subcontractor.
3. Not employ an applicant for employment or contract with a potential subcontractor to perform any duties that may be paid for directly or indirectly through a contract if the applicant or potential subcontractor is listed on LEIE.
4. Prohibit an employee or subcontractor listed on any LEIE from performing any duties that may be paid for directly or indirectly through a contract; and
5. if an employee or subcontractor is listed on either LEIE immediately report to the HHS Office of Inspector General, in accordance with the self-reporting protocol of the HHS Office of Inspector General:
   • the identity of an excluded employee or subcontractor; and
   • the amount paid by the contractor to the employee or subcontractor for services provided under a contract.