New Employee--Dietitian Name* First Last Name BadgePreference of how you prefer your name badge to read. Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I-9 E-Verify: Will need copy of card(s) for I-9 E-VerifyCopy of Driver's License*Max. file size: 20 MB.Copy of Social Security Card*Max. file size: 20 MB.Are you legally eligible for employment in this country?* Yes No Are you able to perform the essential functions of the job with or without a reasonable accommodation?* Yes No Health InformationPhysicalCopy of physical confirming that you are able to perform the essential functions of the job with or without restrictions, and free of communicable disease.Max. file size: 20 MB.Immunization RecordsCopy of Mantoux tuberculin skin test (required), Hepatitis vaccinations, Influenza shot. Please provide copies of any of these that you have.Max. file size: 20 MB.COVIDCopy of vaccination cardMax. file size: 20 MB.COVID WaiverCopy of waiver application and any supporting documentation Max. file size: 20 MB.Drug ScreenCopy of 10-panel drug screen. We will set up an appointment for this to be completed. Max. file size: 20 MB.Education & CredentialsEducation*UniversityGraduation DateDegree CDR Number:* Credentials*Certification/License or Related CredentialsState if applicable EmploymentEmployment History*Previous EmployerDates of EmploymentPositionSupervisorEmployer Contact Information Attach resume Drop files here or Select files Max. file size: 20 MB. Explain any gaps in your employment, other than personal illness, injury, or disability.*Have you ever been terminated or asked to resign from a job? If yes, please explain.* Yes No ExplanationPlease list any computer skills, including any Electronic Medical Record systems you have previously utilized.ReferencesProvide 3 references. References*NameCompanyTitleRelationship to YouPhoneEmailNumber of Years Known I agree to allow my references to be contacted.* Yes No Professional MembershipsProfessional memberships, MIGs, DPGs, or Related Volunteer ActivitiesEmergency ContactIn case of emergency at work please list your emergency contact person. Name First Last PhoneRelation to you DisclaimersI acknowledge that Indiana is at “at will” state.* Yes No I agree to allow for a background check.* Yes No I understand that I must obtain a Dietitian Certification/License or hold a Certification/License in good standing for the state in which I will work.* Yes No The information provided in this Application for Employment is true, correct and complete. If employed, any misstatements or omissions of fact on this application may result in my dismissal. I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. I understand that Nutrition Services, Inc. is an Equal Opportunity Employer. No question on this application form is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state or federal law. Equal access to employment, services and programs is available to all persons.* Date
