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By clicking the submit button below, I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

By clicking the submit button below, I certify that I am not currently excluded, debarred, suspended, or otherwise ineligible to participate in the Federal health care programs nor have I been convicted of a:

  • criminal offense that is related to the delivery of an item or service under Medicare or any state health care program
  • criminal offense relating to neglect or abuse of patients
  • felony criminal offense relating to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct in connection with the delivery of a health care item or service or with respect to a government funded health care program (other than Medicare or a state health care program);
  • felony criminal offense relating to the unlawful manufacture, distribution, prescription or dispensing of a controlled substance, but has not yet been excluded, debarred, suspended, or otherwise declared ineligible.