Employee Cover Sheet
*
Please email the following documents and complete the application in its entirety:
Resume'
Diploma and/or Degree
Official Transcript
Social Security Card
Driver's License
Current Car Insurance
Professional License and/or Insurance
3 Professional References letters Direct Deposit Information
CPR/First Aid Certification
https://www.nationalcprfoundation.com
(BLS for Healthcare Providers Course)
NPI Number
https://npiresgistry.cms.hhs.gov
(Taxonomy for Non-Licensed Behavioral Health Staff -171M00000X)
* *Complete application in its entirety, lack thereof will result in processing delay and applicant will NOT be able to begin work until doing so**
Employee Cover Sheet:
Employee Name
Application Type:
New Employee
Established Employee Update
Discharged Employee Update
Pay Rate Update
Effective Date
First Name
*
Last Name
*
Date of Birth
SSN
Email Address
*
Site Location
Hourly Rate
Job Title
Diploma/Degree
Full Address
Mailing Address ( Only complete if different from home address. )
Contact Information:
Home Phone
Cell
Other Phone
Upload Resume
Submit
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