Provider Application Form

 

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[br][/br]Welcome to P3 Connect! [br][/br]Please fill out our secure form to get started.

Contact Information

Title

Add New

First Name

Last Name

Suffix

Social Security #

DOB

Email Address

Gender

Phone

Fax

Cell

Home Address

City

State

Zip

Your Preferences

Subject Preference

Grade Preference

Foreign Language(s) Fluency

Foreign Language(s) Certification

Availability

Area(s) Willing to Work

Days Available

Hours Available

Summer Availability

Comments

Background Info

Education

School

Location

Graduated

Diploma/Degree

Major

Have you been an employee of the DOE in the past year?

Are you a current employee of the DOE?

Employees of the DOE are not permitted to work as Independent Providers unless they receive a waiver.

Do you have any friends or relatives that have worked for P3 Connect? (Please List)

Do you play any Musical Instruments? (Please List)

Criminal Background Check

Have you ever been convicted of or pleaded guilty to any criminal offense?

For purposes of this application, a Criminal Offense is a felony and/or misdemeanor. (Which include, but is not limited to, traffic offenses such as DWI or DUI but does not include speeding tickets or tickets for non-moving violations.)

If yes, please explain briefly:

Your responses may be verified by a criminal record check if allowed by law. Conviction of a criminal offense does not automatically bar a person from providing services through P3 Connect. Factors such as federal, state or local statutory requirements, the relationship of the offense to the services, the length of time since the offense and the seriousness and nature of the violation will be taken into account. [br][/br][br][/br][br][/br]

Previous Employment

List all periods of employment for the last 10 years, or last 4 employers. Include any periods of unemployment.

Employer

Position

Date Started

Date Ended

Contact Person

References

Name

Company

Position

Phone

[br][/br][br][/br][br][/br]

Agreement

[br][/br]1. The information I have provided on this application is accurate to the best of my knowledge and subject to verification by P3 Connect. I understand that any misrepresentation or omission of fact in my application or resume will be grounds to nullify any future contracts / agreements between me and P3 Connect.

2. Upon accepting a case from P3 Connect to service a student, I will not service that student in any capacity as an independent provider, or through another agency during that school year and for two years following the termination of service for that student.

3. I understand that this application is not a contract and does not contain any assurance or agreement to hire and or compensate me in any way.

4. The Immigration and Reform Act of 1986 requires that every individual hired be authorized to work in the United States. I understand that if hired I will be required to present proper documentation of my work eligibility and identification.

5. In the case of any future disagreement with P3 Connect Inc, I accept binding arbitration of the Beit Din Btzedek Tishpot of Brooklyn, NY (formerly Rav Yisroel Belsky zt”l).[br][/br][br][/br][br][/br]

P3 Connect Inc. does not discriminate in its hiring practices on the basis of age, color, disability, marital status, national origin, race, religion, gender, sexual orientation, veteran status, or other legally protected categories.[br][/br][br][/br][br][/br]

Background Check Authorization

This form authorizes the collection of information that will be used to generate a consumer report, which will be used to determine suitability for employment by P3 Connect Inc.

I, the undersigned consumer, do hereby authorize P3 Connect Inc. to procure a consumer report and/or investigative consumer report on me for employment purposes. These above-mentioned reports may include, but are not limited to, information as to my character, general reputation, and personal characteristics, discerned through employment and education verifications (to include GPA). I understand that this authorization and release shall be valid for subsequent consumer and/or investigative consumer reports during my period of employment with P3 Connect for the purpose of investigating any incidents of workplace misconduct or criminal activity for which I am alleged to have been involved during my employment. I understand in some instances P3 Connect employees may be placed by P3 Connect to work in other facilities such as schools, government agencies, etc. By signing this release, I also hereby authorize P3 Connect to share my consumer report and/or my investigative report with said schools, government agencies, etc. if P3 Connect places me with such a facility. I understand I am entitled to a complete and accurate disclosure of the nature and scope of any consumer report of which I am the subject upon written request to P3 Connect Inc., if such a request is made within a reasonable time after the date hereof. I also understand I may receive a written summary of my rights under 15 U.S.C. § 1681 et. seq.

Additional required documents

Attach W-9 Form

To digitally fill and sign a copy of the w9 form, click here.

Attach Your Photo ID

Attach Your License / Certification

Attach Your Resume

Attach a Recent Photo of Yourself

Direct Deposit Information (optional)

P3 Connect pays via direct deposit. Please fill out your direct deposit info below to avoid delays in payment. If you do not wish to provide this information at this time, we will request it at a later date:

Name of Bank

Name on account if different than above:

9 Digit Routing #

Account #

Re-Type Account #

Type of account:

P3 Connect Inc. is hereby authorized to directly deposit my pay to the account listed above. This authorization will remain in effect until I modify or cancel it in writing.

I, [formula]A6+" "+A7[/formula], certify that the information I have provided above is accurate and true to the best of my knowledge, and I agree to all of the above.

Signature

Date

Record #

Merged to Provider DB

DOB validation

Account number validation

Created

Digital Application is signed

Link to this record

'Merge to Provider Record' executed time