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Multi-line address
Birthday
Month
Day
Year
Do you have a valid driver’s license?
Have you ever been convicted of violating any federal, state, county, or municipal law, regulation, or ordinance? (Do not include minor traffic violations.)
Have you ever been sanctioned by any federal or state authority for Medicare or Medicaid fraud, waste, or abuse?
Have you ever applied to Focus 1 Health Consulting?
Do you have any relatives currently employed by Focus 1 Health Consulting?
Type of Work (Check all that apply)
Are there any specific days of the week when you are unavailable to work?
Highest level of education completed:

Certificates/Licenses/Registrations

Are you applying for a position that requires a professional registration, license, or certification?
No
Yes
Type:
Expiration Date
Month
Day
Year
Is your license application currently in progress?

Employment History

Please provide a complete seven-year employment history, beginning with your most recent employer. Failure to include all previous employers may result in disqualification from consideration or termination of employment

Are you presently employed?
May we contact your present employer?
Dropdown
Type of Work (Check all that apply)
Type of Wage
Start Date
Month
Day
Year
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