All forms must be completed using your legal name as indicated on your Social Security Card and returned by
NOTE: The "Health Statement" requires a physical exam, supporting documentation for TB Skin Tests, labs & vaccinations. Please plan on meeting the requirements prior to your start date and while you still have access to healthcare.
Employee Identification Numbers will be filled in by HR.
Print, legibly complete and mail all original forms to:
UCSF Fresno Center
Attn: Dyan Ruelas
155 N. Fresno Street, #251
Fresno, CA 93701
For MDs Only
For DOs Only
If Applicable Forms
Nonresident Alien Forms (if applicable)