1. If employed and under 18 years of age, can you furnish a work permit?*

2. Have you filed an application with this company before? *

3. Have you ever been employed with this company before?*

4. Are you currently employed?*

If yes, may we contact your present employer? *

5. Are you able to work?*

6. Have you ever been excluded from participation in any federally funded health care program, including but not limited to Medicare and Medicaid? *

7. If licensed, have you ever been sanctioned (disciplined by the licensing board)?*