First Name*
Last Name*
Email Address*
Phone*
Cover Letter*
Who referred you to this position? Enter their first and last name here.
Do you have a valid driver's license?*
No answer Yes No
What's your citizenship / employment eligibility?*
No answer I am a U.S. Citizen/Permanent Resident Non-citizen allowed to work for any employer Non-citizen allowed to work for current employer Non-citizen seeking work authorization I am a Canadian Citizen/Permanent Resident Other
Are you 18 years of age or older?*
No answer Yes No
Are you currently enrolled in a college/university?*
-- No answer -- Yes No
Please provide the name of the college/university you're enrolled in.*
Current year of study?*
-- No answer -- Freshman Sophomore Junior Senior
What level of degree program are you currently working towards?*
-- No answer -- Bachelor's Master's PhD
Is an internship/preceptorship required for your current degree program?*
-- No answer -- Yes No
If SERV is able to offer you an internship/preceptorship, what date must you begin work?*
Please describe your expectations for an internship/preceptorship.*
Pursuant to federal law, the Office of Inspector General's recommendations, and SERV's Compliance Plan, each applicant must answer and certify the following questions:*
-- No answer -- Yes No
Are you currently charged with a criminal offense related to the delivery of health care services?*
-- No answer -- Yes No
Have you ever been convicted of a crime, entered into a plea bargain, or other arrangements with prosecuting authorities relating to any of the following? (check all that apply)*
If yes to any, please give date(s) and a brief description of the offense and sentence. (If none enter N/A)*
Have you ever been found civilly or criminally liable for abuse/neglect?*
-- No answer -- Yes No
Have you ever been excluded (or proposed for exclusion) from the Medicare or Medicaid programs or any other Federally funded health care program, or had a civil monetary penalty or administrative fine imposed against you?*
-- No answer -- Yes No
If yes, please give the date and a brief description of the offense resulting in the penalty and date of reinstatement. (If none enter N/A)*
Have you previously worked for SERV?*
-- No answer -- Yes No
Can you perform this job's required duties with or without reasonable accommodations?*
-- No answer -- Yes No
Do you have any relatives who currently work for SERV?*
-- No answer -- Yes No
If yes, please provide the name of the relative. (If no enter N/A)*
Do you have a valid and current driver's license in the state you currently live in?*
-- No answer -- Yes No
I am able to attend a one to two week onboarding training from 9AM to 5PM. (This is a one-time requirement)*
-- No answer -- Yes No
Invitation for Job Applicants to Self-Identify as a U.S. Veteran
A “disabled veteran” is one of the following:
a veteran of the U.S. military, ground, naval or air service who is entitled to compensation (or who but for the receipt of military retired pay would be entitled to compensation) under laws administered by the Secretary of Veterans Affairs; or
a person who was discharged or released from active duty because of a service-connected disability.
A “recently separated veteran” means any veteran during the three-year period beginning on the date of such veteran's discharge or release from active duty in the U.S. military, ground, naval, or air service.
An “active duty wartime or campaign badge veteran” means a veteran who served on active duty in the U.S. military, ground, naval or air service during a war, or in a campaign or expedition for which a campaign badge has been authorized under the laws administered by the Department of Defense.
An “Armed forces service medal veteran” means a veteran who, while serving on active duty in the U.S. military, ground, naval or air service, participated in a United States military operation for which an Armed Forces service medal was awarded pursuant to Executive Order 12985.
Voluntary Self-Identification of Disability
Voluntary Self-Identification of Disability Form CC-305
Why are you being asked to complete this form?
How do you know if you have a disability?
