Last Name* Req'd	First Name* Req'd	Middle Initial
Mailing Address * Req'd	City * Req'd	State * Req'd
Zip Code * Req'd	Fax No. * Req'd	Active * Req'd New Employee Lay-off/Fired Temporary Leave Update/ Change Existing
Primary Service Location * Req'd Winters Behavioral Health Winters HC Home Winters HC Prenatal Winters HC Dental Winters HC Medical Cottonwood HC Center Courtyard Health Sierra HC Univ. Ret. Center	Male * Req'd Female * Req'd

Role: * Req'd Accounting Billing Billing Manager Care Coordinator Dental Front Office Front Office Supervisor MA Nurse MA Nurse Supervisor	Resource * Req'd if schedule needed Yes No	Start Date* Req'd

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