Inner G Wellness

Full Legal Name *

Preferred Name (if different)

Email Address *

Phone Number *

City, State of Residence *

Are you legally authorized to work in the United States? *

Are you willing to undergo background screening if required by contract? *

Background Screening History (if applicable):

Completed within last 12 months

Completed within last 24 months

Not applicable

Unknown

Current Clearance Status:

(Select all that apply. Do not initiate clearance based on this form)

None

Public Trust (Low Risk)

Public Trust (Moderate Risk)

Public Trust (High Risk)

Clearance Status:

Active

Expired

Eligible but not initiated

Previously held (no longer active)