New Beginnings Counseling Service

New Beginnings Counseling Service

Application for Employment

Date: ______

Name: ______

LastFirstMiddle

Social Security #: ______

Therapy License # (if applicable): ______

Home Phone: ( )______Alt. Phone: ( )______

Address: ______

Street CityStateZip

Position applied for: ______

Expected Salary/Wage? ______

Are you a minimum of 18 years of age? ____Yes ____No

When are you available to begin working? ______

How did you hear about this position? ______

Do you have a record of founded child or dependent adult abuse or are you currently under investigation for this? ____Yes ____No

If yes, please explain: ______

______

______

Have you been provided a copy of the core roles for this position and are you able, with or without reasonable accommodation able to perform the essential role of the job? ____Yes ____No

Comments: ______

______

Do you have a valid driver’s license? ____Yes ____No

Can you provide your own transportation on the job? ____Yes ____No

High School attended: ______

Did you Graduate? ____Yes ____No

Educational History

Please list any colleges or universities you attended, major, and degree earned. Attach additional page if needed: ______

______

______

______

May we contact you previous employers? ____Yes ____No

If No, specify who we may not contact: ______

______

History of Employment

Please list all relevant job experience you feel relates to your desired position. Attach an additional page if needed:

Employer: ______

Supervisor: ______Phone: ( )______

Address: ______

Position: ______

Period employed: ______through ______

Please Circle: Full-time or Part-time

Reason for Leaving: ______

Job responsibilities: ______

______

History of Employment (cont.)

Employer: ______

Supervisor: ______Phone: ( )______

Address: ______

Position: ______

Period employed: ______through ______

Please Circle: Full-time or Part-time

Reason for Leaving: ______

Job responsibilities: ______

______

______

Employer: ______

Supervisor: ______Phone: ( )______

Address: ______

Position: ______

Period employed: ______through ______

Please Circle: Full-time or Part-time

Reason for Leaving: ______

Job responsibilities: ______

______

______

History of Employment (cont.)

Employer: ______

Supervisor: ______Phone: ( )______

Address: ______

Position: ______

Period employed: ______through ______

Please Circle: Full-time or Part-time

Reason for Leaving: ______

Job responsibilities: ______

______

Employer: ______

Supervisor: ______Phone: ( )______

Address: ______

Position: ______

Period employed: ______through ______

Please Circle: Full-time or Part-time

Reason for Leaving: ______

Job responsibilities: ______

______

______

Personal References

Please provide three references that we may contact. Do not list former employers or relatives.

Name: ______Occupation: ______

Relationship: ______Number of years known: ______

Phone: ( ) ______Alt. Phone: ( ) ______

Address: ______

Name: ______Occupation: ______

Relationship: ______Number of years known: ______

Phone: ( ) ______Alt. Phone: ( ) ______

Address: ______

Name: ______Occupation: ______

Relationship: ______Number of years known: ______

Phone: ( ) ______Alt. Phone: ( ) ______

Address: ______

I have read and understand this application and certify that the information provided by me in this application is true and accurate. Furthermore, I understand that any falsification, misrepresentation, or omission on this application is grounds for refusal to hire, or if hired, grounds for dismissal from employment.

I authorize all provided references, current and former employers, and law enforcement authorities, whether listed on this application or not, to release information to New Beginnings Counseling Service regarding my background and work experience. I hereby release and hold harmless New Beginnings Counseling Service from any liability or damage whatsoever for providing or issuing information.

Employment and continued employment is contingent upon the successful completion of criminal record checks, child/adult abuse checks, reference checks, motor vehicle driving records, and any other consumer report that may contain public record information about you.

I understand that New Beginnings Counseling Service maintains a drug free violence free work environment, and as an employee I am expected to maintain the same as it is essential to a safe work environment.

New Beginnings is an equal opportunity employer. Employment opportunities are open without regard to race, color, creed, national origin, gender, marital status, sexual orientation, age, religion, veteran status, political belief, physical or mental disability, or any other characteristic protected by law. No information obtained during interviewing, reference checks, or any other means will be used to discriminate on the basis of any characteristics protected by law.

I understand that, if hired, my employment is considered to be at will and can be terminated by either party at any time with or without cause. New Beginnings Counseling Service reserves the right to terminate without any notice.

I understand that this application, the granting of an interview and any documents I receive are not contracts of Employment. I acknowledge that any offer of employment is conditional and may be withdrawn at any time.

______

Signature of ApplicantDate