Round One: Documents Needed for Potential Hire
Please upload or enter the additional items below:
Please enter your name:
*
First Name
Last Name
Please enter your place of birth below:
*
Include city, state, and country
Please enter the last 7 years of residential information (previous addresses):
*
Include street, city, state, and country
Please upload a copy or photo of your drivers license:
*
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Please upload a copy or photo of your social security card:
*
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Please upload a copy or photo of your COVID-19 Vaccination card (or exemption letter):
*
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Please upload a copy or photo of your diploma:
*
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Please upload a copy or photo of your proof of citizenship/work permit (if applicable):
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Please upload a copy or photo of your DEA license (if applicable):
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Please upload a copy or photo of your professional license (if applicable):
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Please enter your NPI number (if applicable)
Please enter your Medicaid number (if applicable)
Please enter your CAQH number (if applicable)
Thank you!
Community Behavioral Health Center
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