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Lao Democratic Republic
Papua New Guinea
Saint Vincent Grenadines
Sao Tome and Principe
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United Arab Emirates
How did you hear about us?
Agency Recruiter (please specify)
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I am a Current Employee
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Other (Specify Source):
Are you 18 years or older:
For any employer
For my present employer only
With sponsorship now or in future
My status is unknown
Can you, after employment, submit verification of your identity and right to work in the United States?
ID & Right to work:
Highest Education Level:
High School Diploma / GED
Trade or Technical School Diploma
Willing to relocate:
If no relocation, explain:
Willing to travel (%):
Have you ever worked for NextGen Healthcare or Quality Systems, Inc.?
Worked for NextGen:
Worked for QSI:
Worked where & when:
Worked what position:
Have you ever previously applied
at NextGen Healthcare or Quality Systems, Inc.?
Applied at NextGen:
Applied at QSI:
Applied where & when:
Applied what position:
Do you have any relatives that work for QSI/NextGen Healthcare, Mirth or HealthFusion? If so, what is their job or what area do they work In?
No Prior Employment
Professional Achievements and Memberships:
Membership in professional or job-relevant organizations (You may exclude groups that indicate race, color, religion, national origin, disability, or other protected status):
Publications, patents, inventions, professional licenses, or additional special honors or awards:
Have you ever held a Security clearance? If yes, give name of Employer, level of clearance and inclusive dates below.
Have you ever had a Security clearance suspended, denied or revoked? If yes, please explain below.
Security denied details:
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I hereby certify that the answers given by me to the foregoing questions and statements are true and correct, without mental reservation of any kind whatsoever, and hereby authorize NextGen Healthcare Information Systems, Inc., or its parent company, Quality Systems, Incorporated, to verify same. If employment is obtained under this application, I will comply with all orders, rules and regulations of the company. I agree to submit to physical examination upon request. I also authorize my former employers and educational institutions to give any information they may have regarding me. I hereby release them and their organizations from all liability for any damages whatsoever for issuing same.
If, upon investigation, anything contained in this application is found to be untrue or information subsequently becomes known to Company that, in Company's sole opinion, alters Company's understanding of the contents of my application, I understand that Company may withdraw the offer made to me and/or I may be subject to dismissal at any time during the period of my employment.
Electronic Signature Date:
Format: M/D/YY *
Voluntary Equal Opportunity Questionnaire
As an equal opportunity employer, we hire without consideration to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, veteran status or disability. We invite you to complete the optional self-identification fields below used for compliance with government regulations and record-keeping guidelines.
Choose Not to Disclose
Hispanic or Latino
White (not Hispanic or Latino)
Black or African American (not Hispanic or Latino)
Native Hawaiian or Other Pacific Islander (not Hispanic or Latino)
Asian (not Hispanic or Latino)
American Indian or Alaska Native (not Hispanic or Latino)
Two or More Races (not Hispanic or Latino)
Choose Not to Disclose
Other Protected Veterans
Armed Forces Service Medal Veterans
Recently Separated Veterans
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Candidate Individual with disabilities:
Voluntary Self-Identification of Disability Form CC-305 OMB Control Number 1250-0005 Expires 1/31/2020
Why are you being asked to complete this form?
Because we do business with the government, we must reach out to, hire, and provide equal opportunity to qualified people with disabilities.
i To help us measure how well we are doing, we are asking you to tell us if you have a disability or if you ever had a disability. Completing this form is voluntary, but we hope that you will choose to fill it out. If you are applying for a job, any answer you give will be kept private and will not be used against you in any way. If you already work for us, your answer will not be used against you in any way. Because a person may become disabled at any time, we are required to ask all of our employees to update their information every five years. You may voluntarily self-identify as having a disability on this form without fear of any punishment because you did not identify as having a disability earlier.
How do I know if I have a disability?
You are considered to have a disability if you have a physical or mental impairment or medical condition that substantially limits a major life activity, or if you have a history or record of such an impairment or medical condition. Disabilities include, but are not limited to:
Reasonable Accommodation Notice
Federal law requires employers to provide reasonable accommodation to qualified individuals with disabilities. Please tell us if you require a reasonable accommodation to apply for a job or to perform your job. Examples of reasonable accommodation include making a change to the application process or work procedures, providing documents in an alternate format, using a sign language interpreter, or using specialized equipment.
i Section 503 of the Rehabilitation Act of 1973, as amended. For more information about this form or the equal employment obligations of Federal contractors, visit the US. Department of Labor's Office of Federal Contract Compliance Programs (OFCCP) website at www.dol.gov/ofccp. PUBLIC BURDEN STATEMENT: According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. This survey should take about 5 minutes to complete.