Online Application Submission

SECTION 01: Basic InformationStep 1 of 14

Applicant's First Name: *

Applicant's Last Name: *

Applicant's Date of Birth: *

Applicant's Social Security #: *

Applicant's Phone #: *

Applicant's Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Applicant's Email Address: *

High School Name: *

High School Location (City / State): *

High School Graduation Year: *

University / College / Trade School - Name (01): *

University / College / Trade School - City / State (01): *

Year of Graduation (01): *

Degree in (01): *

Professional License #: *

OPTIONAL - University / College / Trade School - Name (02):

University / College / Trade School - City / State (02):

Year of Graduation (02):

Degree in (02);

Current / most recent employer - Name: *

Current / most recent employer - Phone #: *

Current / most recent employer - Address: *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Current / most recent employer - Your Title: *

Current / most recent employer - Salary: *

Current / most recent employer - Your job duties and responsibilities: *

Current / most recent employer - Reason for leaving: *

Current / most recent employer - Employment start and end date: *

OPTIONAL Previous employer - Name:

Previous employer - Phone #:

Previous employer - Address:

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Previous employer - Your Title:

Previous employer - Salary:

Previous employer - Your job duties and responsibilities:

Previous employer - Reason for leaving:

Previous employer - Employment start and end date:

Professional References - Name (01): *

Professional References - Relationship (01): *

Professional References - Occupation (01): *

Professional References - Phone # (01): *

Professional References - Email Address (01):

Professional References - Address (01):

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Professional References - Name (02): *

Professional References - Relationship (02): *

Professional References - Occupation (02): *

Professional References - Phone # (02): *

Professional References - Email Address (02):

Professional References - Address (02):

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Physical Record - are you currently physically injured? *

Physical Record - If YES, provide details: *

Physical Record - Do you have any physical disabilities that would prevent you from performing the work for which you are applying?: *

Physical Record - If YES, please describe: *

Licenses / Certifications - Type (01): *

Licenses / Certifications - # (01): *

Licenses / Certifications - State Issued (01): *

Licenses / Certifications - Expiration Date (01): *

OPTIONAL - Licenses / Certifications - Type (02):

Licenses / Certifications - # (02):

Licenses / Certifications - State Issued (02):

Licenses / Certifications - Expiration Date (02):

OPTIONAL - Areas of specialized study, research or additional experience:

OPTIONAL - List the foreign languages that you are fluent in (speak, read, write):

Emergency Contact - Name: *

Emergency Contact - Relationship: *

Emergency Contact - Phone #: *

Emergency Contact - Address:

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Authority: This form shall be used by all employees to comply with:

• the attestation requirements of section 435.05(2), Florida Statutes, which state that every employee required to undergo Level 2 background screening must attest, subject to penalty of perjury to meeting the requirements for qualifying for employment pursuant to this chapter and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses while employed by the employer; AND

• the proof of screening within the previous 5 years in section 408.809(2), Florida Statutes, which requires proof of compliance with level 2 screening standards that have been screened through the Care Provider Background Screening Clearinghouse created under Section 435.12, F.S., or screened within the previous 5 years by the Agency, Department of Health, Department of Elder Affairs, the Agency for Persons with Disabilities, Department of Children and Families, or the Department of Financial Services for an applicant for a certificate of authority to operate a continuing care retirement community under Chapter 651, F.S., and in accordance with the standards in Section 408.809(2), F.S., if that agency is not currently implemented in the Care Provider Background Screening Clearinghouse.

This form must be maintained in the employee's personnel file. If this form is used as proof of screening for an administrator or chief financial officer to satisfy the requirements of an application for a health care provider license, please attach a copy of the screening results and submit with the licensure application.

You must attest to meeting the requirements for employment and you may not have been arrested for and awaiting final disposition of, have been found guilty of, regardless of adjudication, or have entered a plea of nolo contendere (no contest) or guilty to, or have been adjudicated delinquent and the record has not been sealed or expunged for, any offense prohibited under any of the following provisions of state law or similar law of another jurisdiction.

For more information on Florida Statutes: Title XXX: ILABOR Chapter 435: EMPLOYMENT SCREENING SECTION 04: Level 2 screening standards

Visit: https://m.flsenate.gov/Statutes/435.04

01. Have you been granted an exemption from disqualification through the Agency for Healthcare Administration (AHCA)? *

If YES, attach the exemption from disqualification decision letter from the Agency for Healthcare Administration (AHCA). *