The following information is requested to assist us in assessing the effectiveness of our recruiting activities. Your cooperation is appreciated. How did you hear about this job? PLEASE CHECK ONLY ONE:
|
Are you related to a current employee within the department you are applying?
If yes, list names and relationships:
(Includes spouses, children, parents, in-laws, siblings, legal dependents,
members of the same residence, or any person who fulfills an immediate
family role for you.)
Have you been subject of any adverse action(s) by any duty authorized sanctioning or disciplinary agency for either conduct based or performance based actions?
If yes, explain:
Have you ever been excluded, suspended, or debarred from,
or otherwise declared ineligible to provide services in the Medicare or Medicaid programs,
or any other federally-funded health care program?
|