Application For Employment - Pines Behavioral Health

PERSONAL INFORMATION

Date:*

Phone*

First Name*

Middle Name*

Last Name*

Present Address:*

Street Address City State / Province / Region Postal / Zip Code

Permanent Address:

Street Address City State / Province / Region Postal / Zip Code

Email Address:*

Are you 18 years of age or older?*

Yes

Are you prevented from being lawfully employed in this country because of Visa or Immigration Status?*

Yes

Have you ever been convicted of a crime? *

Yes

Have you ever been convicted of a crime? If yes, explain:

Have you ever been convicted of a crime? If yes, explain:(1)

If yes, was this crime against a child? *

Yes

Non-applicable

A conviction record will not necessarily be a barrier to employment. Other factors such as age, and time of theoffense; the seriousness, the nature of the violation, and rehabilitation will be considered.

Are there any felony charges pending against you?*

Yes

Have you ever been sanctioned by Federal or State regulatory or licensing agency?*

Yes

Have you ever been sanctioned by Federal or State regulatory or licensing agency? If yes, explain:

If no, is a potential action involving sanction pending?*

Yes

Driver’s license number:*

State of Issue:*

State / Province / Region

EMPLOYMENT

Position applying for:

Date available for work:

Are you currently employed?

Yes

If so, may we contact your present employer?

Yes

Employer Phone #:

Have you applied to or worked for us previously?

Yes

Give Specifics:

EDUCATION

High School

High School Name/Location of School

High School # Yrs. Attended

High School Did you graduate?

College (Bachelors)

College (Bachelors) Name/Location of School

College (Bachelors) # Yrs. Attended

College (Bachelors) Did you graduate?

College (Bachelors) Subject/Major

College (Advanced Degree)

College (Advanced Degree) Name/Location of School

College (Advanced Degree) # Yrs. Attended

College (Advanced Degree) Did you graduate?

College (Advanced Degree) Subject/Major

Professional Certification:

State:

Type:

Number:

Exp. Date:

GENERAL

Subject of special study, research work or publications:

Special Skills:

Are you fluent in other languages besides English?

Yes

Please indicate what other languages you're fluent in:

Activities (Civic, athletic, etc.) that you are or have been involved in that are relevant to the position you are applying for:

U.S. Military Service:

If applicable, what education, training, or work experience did you learn in the military relevant to this position?

FORMER EMPLOYERS STARTING WITH LAST ONE FIRST

(1) Employed with:

(1) Dates: From and To

(1) Position:

(1) Salary:

(1) Reason Left:

(1) Describe duties:

(2) Employed with:

(2) Dates: From and To

(2) Position:

(2) Salary:

(2) Reason Left:

(2) Describe duties

(3) Employed with:

(3) Dates: From and To

(3) Position:

(3) Salary:

(3) Reason Left:

(3) Describe duties:

(4) Employed with:

(4) Dates: From and To

(4) Position:

(4) Salary:

(4) Reason Left:

(4) Describe duties:

PLEASE NOTE: YOU ARE REQUIRED TO LIST THE NAME OF 2 CURRENT SUPERVISORS AS A
REFERENCE

(1) SUPERVISOR:

(1) Name

First

Last

(1) Firm:

(1) Address

Street Address City State / Province / Region Postal / Zip Code

(1) Telephone Number:

(2) SUPERVISOR:

(2) Name

First

Last

(2) Firm:

(2) Address

Street Address City State / Province / Region Postal / Zip Code

(2) Telephone Number:

AUTHORIZATION & WAIVER
I hereby certify that the information I have provided verbally and on my application and accompanying resume and documents, if any, is true and complete. I have not knowingly withheld any information that might, if disclosed, would affect my application unfavorably. I understand, and agree, that any information provided by me, either written or verbal, which proves to be false, misleading, or incomplete, may prevent me from being hired. If hired, this may be grounds for discipline or dismissal from employment if discovered at a later date.

I authorize Pines Behavioral Health Services (“PBHS”) to make any investigation into my background deemed necessary, including, but not limited to, investigation and verification of references, educational transcripts and records, employment records, disciplinary information, and criminal conviction history. I authorize all references, previous employers, schools, educational institutions, military organizations, and other persons having information about me in order to release to PBHS any and all information and opinions concerning me - personal or otherwise - whether or not such information is part of their written records, including disciplinary, academic, service or performance records, without providing me notice of such release. I also authorize and request federal, state, and local governmental agencies to release to PBHS any information requested concerning any criminal convictions on my record.

Without limitation, I release all parties mentioned in this paragraph from any and all liability and damages for releasing such information. I specifically release PBHS, its governing board, officers, employees, and/or agents from any and all claims and/or liability whatsoever for any damages or consequences which result from its investigation of me. A photocopy of this signed authorization and waiver shall be as valid as an original.

Date

Signature*