Employee Application

Employee Application
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Email*
example@example.com
Gender*
Social Security*
Proof of Social Card*

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Tax ID*
State of Birth*
Name of School*
Year of Graduation*

MonthDayYear
Date
NPI*
Provider Type*
State of Licensure *
License *
Proof of License*

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License Effective Date*

MonthDayYear
Date
License Expiration Date*

MonthDayYear
Date
Attach Resume*

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Picture for Photo ID*

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Positions Applied For*
On What Date Would You Be Available to Work?*

MonthDayYear
Date
Are you available to work (F/T, P/T, P/D)*

Full-TimePart-Time
Where Did You Hear About Us?*
Are You Either a U.S. Citizen or an Alien Authorized to Work in the United States?*

YesNo
If Yes, Please Explain*
Are You Prevented From Lawfully Becoming Employed in this Country Because of VISA or immigration status?*

YesNo
If Yes, Please Explain*
Have You Ever Been Dismissed, Involuntarily Terminated or Forced to Resign from Employment?*

YesNo
If Yes, Please Explain*
Application Date*

MonthDayYear
Date
Date of Hire*

MonthDayYear
Date
Add Comments (optional)*
Name of School Education*
Course of Study Education*
Years Completed*
Describe Any Specialized Training, Licenses, Certifications and Skills*
Has any License or Certification You Have Held Been Surrendered, Suspended or Revoked for any Reason? *

YesNo
If So, Please Explain*
Reference 1 Name / Address / Number**
Reference 2 Name / Address / Number**
Reference 3 Name / Address / Number**
If You Have Worked Under a Different Name at Any of the Job(s) Listed, Please Indicate the Different Name and When Used*
Date of Birth*

MonthDayYear
Date
License Number*
State*
Signature*

Clear
Print Name*
Print Former Name*
Date*

MonthDayYear
Date
I have applied for employment with Doppler Wellness. I authorize investigation of all statements contained in the Application for Employment as may be necessary in arriving at an employment decision. I authorize representatives of Doppler Wellness to obtain pertinent information from my previous employers, references and other persons with knowledge of my work history and background, financial history, education, regulatory or police records, driving records, licensing status or professional designation and character or reputation, and to consider the information provided by the background check when making decisions regarding my employment at Doppler Wellness I authorize all previous employers, references, or other persons having knowledge of my record or myself to release such information to, and hereby release all persons from liability.
Signature*

Clear
Print Name*
Date*

MonthDayYear
Date
Have You Ever Been Convicted of or Pleaded Guilty of Nolo Contendere (no contest) to a Violation of any State, Federal, County or Municipal Law? (Do not include traffic violations)*
If Yes, Please Give Information Regarding the Nature of the Charge, the Date and Location of Conviction and the Final Disposition of the Case*
Applicants are not required to disclose the existence of an arrest, criminal charge or conviction for which records have been "erased." The types of records subject to erasure under New York law are as follows: (a) a finding of delinquency or that a child was a member of a family with service needs; (b) a sentence as a youthful offender; (c) a criminal charge that was dismissed or "nolled"; (d) a criminal charge for which the person was found not guilty; and (e) a conviction for which the person received an absolute pardon. Any application whose criminal records were erased will be considered to have never been arrested and may so swear under oath. I understand that the information provided above will not necessarily result in the rejection of my application, but that the nature of the information will be considered as it relates to the performance of the job duties in question and in light of the requirements of state and federal law.
Signature*

Clear
Date*

MonthDayYear
Date
MALPRACTICE
Practitioner*
Department*
If the answer to either of the following questions is YES, please provide details below.
Are There Currently any Pending Medical Malpractice Claims that Have Been Made Against You in any State?*
Have there been any settlements or judgments of medical malpractice against you in the last 2 years in any state?*
Incident Date

MonthDayYear
Date
Nature of Claim (Type of case, procedure, major allegation, carrier, hospital, other pertinent information)
Settled Judge For:
Date and Amount of Disposition
Signature

Clear
Date

MonthDayYear
Date
HEPATITIS B VACCINATION STATUS FORM
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Facility*
Position*
This form is to be signed by all covered individuals who are at risk for occupational exposure to blood or potentially infectious material. I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B Virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B Vaccine, at no charge to myself.

I request immunization, the first vaccination to be administered on.
Date*

MonthDayYear
Date
Signature*

Clear
Date*

MonthDayYear
Date
This position is not a position determined to be at risk of exposure.
Proof of Physical*

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HIPPA

ACKNOWLEDGEMENT OF RECEIPT AND FAMILIARIZATION OF HIPAA, HIV CONFIDENTIALITY TRAINING AND INFECTION CONTROL PRECAUTIONS.
Print Name*
Signature*

Clear
Date*

MonthDayYear
Date
Print Name*
DIRECT DEPOSIT
Name*

First NameLast Name
hereby authorize DOPPLER AT HOME THERAPY to initiate automatic deposits to my account at the financial institution named below. I also authorize DOPPLER AT HOME THERAPY to make withdrawals from this account in the event that a credit entry is made in error. Further, I agree not to hold DOPPLER AT HOME THERAPY responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institution or due to an error on the part of my financial institution in depositing funds to my account. This agreement will remain in effect until DOPPLER AT HOME THERAPY receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to the Payroll Department.
Name of Financial Institution*
Routing Number*
Account Number*
Checking*
Savings*
Signature*

Clear
Authorized Signature (Primary)*

Clear
Date*

MonthDayYear
Date
Authorized Signature (Joint)*

Clear
Date*

MonthDayYear
Date
Please Attach a Voided Check*

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EMPLOYMENT ELIGIBILITY VERIFICATION
►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form. ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination. Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)
Name*

First NameMiddle InitialLast Name
Other Last Names Used*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Employees Email Address*
example@example.com
Employees Telephone Number*
Please enter a valid phone number.
I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form. I attest, under penalty of perjury, that I am (check one of the following boxes):
A Citizen of the United States*

YesNo
A Noncitizen National of the United States*

YesNo
Alien Registration Number/USCIS Number [1]*

YesNo
A Lawful Permanent Resident*

YesNo
An Alien Authorized to Work*

YesNo
Until-Expiration Date, If Applicable*

MonthDayYear
Date
Aliens authorized to work must provide only one of the following document numbers to complete Form I-9: An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.
A Citizen of the United States*

YesNo
Form I-94 Admission Number*
Foreign Passport Number*
Country of Issuance*
Signature of Employee*

Clear
Tomorrow’s Date*

MonthDayYear
Date
A Preparer(s) and/or Translator(s) Assisted the Employee in Completing Section 1*
Signature of Preparer or Translator*

Clear
I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Lists of Required Documents

All documents must be UNEXPIRED

Employees may present one selection from List A

or a combination of one selection from List B and one selection from List C.

LIST A

1. U.S. Passport or U.S. Passport Card

2. Permanent Resident Card or Alien

Registration Receipt Card (Form I-551)

3. Foreign passport that contains a

temporary I-551 stamp or temporary

I-551 printed notation on a machinereadable

immigrant visa

4. Employment Authorization Document

that contains a photograph (Form

I-766)

5. For a nonimmigrant alien authorized

to work for a specific employer

because of his or her status:

Documents that Establish

Both Identity and

Employment Authorization

6. Passport from the Federated States of

Micronesia (FSM) or the Republic of

the Marshall Islands (RMI) with Form

I-94 or Form I-94A indicating

nonimmigrant admission under the

Compact of Free Association Between

the United States and the FSM or RMI

b. Form I-94 or Form I-94A that has

the following:

(1) The same name as the passport;

and

(2) An endorsement of the alien's

nonimmigrant status as long as

that period of endorsement has

not yet expired and the

proposed employment is not in

conflict with any restrictions or

limitations identified on the form.

a. Foreign passport; and

For persons under age 18 who are

unable to present a document

listed above:

1. Driver's license or ID card issued by a

State or outlying possession of the

United States provided it contains a

photograph or information such as

name, date of birth, gender, height, eye

color, and address

2. ID card issued by federal, state or local

government agencies or entities,

provided it contains a photograph or

information such as name, date of birth,

gender, height, eye color, and address

3. School ID card with a photograph

4. Voter's registration card

5. U.S. Military card or draft record

Documents that Establish

Identity

6. Military dependent's ID card

7. U.S. Coast Guard Merchant Mariner

Card

8. Native American tribal document

9. Driver's license issued by a Canadian

government authority

10. School record or report card

11. Clinic, doctor, or hospital record

12. Day-care or nursery school record

LIST B OR AND LIST C

1. A Social Security Account Number

card, unless the card includes one of

the following restrictions:

2. Certification of report of birth issued

by the Department of State (Forms

DS-1350, FS-545, FS-240)

3. Original or certified copy of birth

certificate issued by a State,

county, municipal authority, or

territory of the United States

bearing an official seal

4. Native American tribal document

5. U.S. Citizen ID Card (Form I-197)

6. Identification Card for Use of Resident Citizen in the United States (Form I-179) Documents that Establish Employment Authorization

7. Employment authorization document issued by the Department of Homeland Security

(2) VALID FOR WORK ONLY WITH

INS AUTHORIZATION

(3) VALID FOR WORK ONLY WITH

DHS AUTHORIZATION

(1) NOT VALID FOR EMPLOYMENT

Form I-9 07/17/17 N Page 3 of 3

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.
W9

Please fill out the form using the IRS.GOV link, download it and upload it at the next step.

https://www.irs.gov/pub/irs-pdf/fw9.pdf

Tip: If the link doesn't work, please right click and open in a new tab or copy the link into a new tab.
UPLOAD W9

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Name (as shown on your income tax return}. Name is required on this line; do not leave this line blank.*
Business name/disregarded entity name, if different from above*
Check the appropriate box for Federal tax classification of the person whose name is entered on line 1. Check only one of the following seven boxes.*

Individual/ Sole Proprietor or single-member LLCC CorporationS CorporationPartnershipTrust/EstateLimited Liability CompanyOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
0 Limited Liability Company. Enter the Tax Classification (C=C corporation, S=S corporation, P=Partnership*
Exempt Payee Code (if any)*
List Account Number(s} Here (optional}*
Exemption From FATCA Code*
Employer ID #*
Signature*

Clear
Employees Name in Print*
Signature of Employee*

Clear
Date Signed by Employee*
Employees Name in Print*
Signature of Employee*

Clear
Date Signed by Employee*
Date*

MonthDayYear
Date
Please Upload Proof of Liability

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Should be Empty: