Transition Specialist

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Cover Letter
Licensure

Applicant Name*

First Name

Last Name

Applicant Phone Number*

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Applicant Email

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Type of Licensure*

State of Licensure

License Number

Are you authorized to work in the U.S. on an unrestricted basis?*

Are you legally eligible to work in the country in which this position is located?*

Are you at least 18 years of age?*

Are you a U.S. Citizen?*

Will you now or in the future require the organization to commence (“sponsor”) an immigration case in order to employ you (for example, H-1B or other employment-based immigration case)?*

Do you have relatives who work for our company, or any of TeleMate Health's clients?*

Are you a current or former employee of TeleMate Health or any of TeleMate Health's clients?*

Are you bound by any non-compete agreements or any non-solicitation agreement/order?*

Are you able to perform the essential, job-related functions of the position for which you are applying with or without reasonable accommodation?*

Your position with TeleMate Health may require you to work remotely. Do you have a designated workstation at your residence that is HIPAA compliant and secure? You will be asked to provide evidence as needed based on the job location.*

Do you have internet with a speed of at least 25 mbps?*

Have you been excluded, or are you currently under investigation for healthcare fraud, abuse, or misconduct; or restricted from participating in any Federal or State healthcare program, including Medicare and/or Medicaid?*

Have you ever been convicted, forfeited bond, or are you currently on probation for any felony (or any equal offense under military law)? (A felony is defined as an offense punishable by imprisonment for a term of one year or greater.)*

If yes, give details on a separate sheet of paper for each felony offense. Include (1) date, (2) charge, (3) place, (4) court, and (5) action taken. You must disclose any felony conviction involving a sentence or suspended sentence. You may omit: (1) any offense committed before your 18th birthday which was finally adjudicated in a juvenile court; (2) any conviction which has been expunged under federal or state law. A conviction will not necessarily disqualify you from the job for which you are applying. A conviction will be judged on its own merits with respect to time, circumstances, and seriousness.

I certify that the facts set forth in this Application for Employment are true and complete to the best of my knowledge. I understand that if I am employed, false statements, omissions or misrepresentations may result in my dismissal. I authorize the Employer to make an investigation of any of the facts set forth in this application and release the Employer from any liability. The employer may contact any listed references on this application.I acknowledge and understand that the company is an “at will” employer. Therefore, any employee (regular, temporary, or other type of category employee) may resign at any time, just as the employer may terminate the employment relationship with any employee at any time, with or without cause, with or without notice to the other party.

Applicant Signature:*

Today's Date:*

**OPTIONAL INFORMATION***

VETERANS PREFERENCE:

Tennessee veteran’s preference is extended to applicants listed on the appointment or promotional list. To be eligible for veterans preference, you must have received an honorable discharge from the army, navy, air force, marine corps or coast guard or any member of the reserve components,as defined in 10 U.S.C. § 10101, who performs active federal service in the armed forces of the United States.Proof of dates of military service, honorable discharge, disability, death, and residence are required and must be provided to the Department of Human Resources in order to receive Veterans Preference. A spouse or surviving spouse of a veteran is eligible if these conditions are met: as a result of such military services, the veteran suffered a one hundred (100%) percent service-connected disability or is permanently and totally disabled; or the veteran died in the line of duty during such military service; and the surviving spouse has not remarried since thedeath of the veteran.

Veteran Status*

Applicant Signature:*

**OPTIONAL INFORMATION***

The following information is for Equal Employment Opportunity/Affirmative Action purposes only. To assist the State of TN in its commitment to equal employment opportunity, applicants are asked to voluntarily provide the following information. The State of TN is authorized under federal law to retain this information for research and statistical reasons. This information will not be used in an employment decision and an applicant’s failure or refusal to provide this information will not affect an applicant’s employment opportunities. Data will be held confidential and only used in accordance with applicable federal law. Refusal to provide information will not subject the applicant to any adverse treatment.

Race*

Disability*

Ethnicity*

Gender

Name

First Name

Last Name

Date

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