Unsigned Applications Cannot Be Considered

/ Community Services Institute
Licensed Private Mental Health Clinic / Application Date:
EMPLOYMENT APPLICATION
All of the requested information is crucial to our hiring process. Complete ALL sections. Please DO NOT reference your resume.
Last Name / First Name / M.I. / Preferred Name
Address (include Complete Mailing Address, City, State, & Zip Code
Home Phone: / Cell Phone: / Business Phone:
Email Address: / May we contact you at work?
Yes No
Positions Applying for:
1.
2. / Date available to start? (MM/DD/YYYY)
How did you learn of this position or who referred you?
Have you ever applied to CSI before?
Yes No / If Yes, when and where?
Are you legally authorized to work in the United States? / Yes No
Can you travel within the area if your position requires it? / Yes No
Do you have a valid State Driver’s License? / Yes No
Do you have proof of auto insurance / Yes No
Do you have current CPR Training documentation? / Yes No
Do you have current First Aid Training documentation? / Yes No
Please indicate your availability: / Overtime Weekends Evening Shifts
Please indicate any other work schedule restrictions:
Do you speak any language other than English that might help you perform your job?
If Yes, list each and indicate level of fluency to speak, read, and write: / Yes No
Miscellaneous Skills and Knowledge:
Keyboarding Skills (proficiency will be tested): / None Limited Proficient Advanced
Computer Software (list software):
Computer Hardware Skills (describe):
Other technology Skills (describe)
EDUCATION & TRAINING

Please complete this section in addition to submitting a resume. Start from your most recent or current position. You may include volunteer positions. Ensure you document a minimum of a 10 year employment history.

High School Diploma or GED? / Yes No / If No, indicate highest grade completed:
School, Mailing Address, City, State, Zip / Course of Study/Major / Did you graduate? / Date of Graduation
(MM/YY) / Degree Awarded
College or University: / Yes
No
College or University: / Yes
No
Graduate School: / Yes
No
Business , Trade, Vocational, Other:
Other Training (Certificates or Job Related Training):
Volunteer/Internship Experience (Please list duration and position held):
Clinical Credentials: Please indicate all CURRENT, valid credentials. If hired, documentation will be required and verified.
Mass. LCSW
Mass. LMHC
Mass. LMFT
Mass. LICSW
Other M.H. License
Mass. Psychologist
Registered Nurse
Advanced RN Practitioner
Psychiatrist (M.D. or D.O) / License/Registration Type and #: / Expiration Date:
License/Registration Type and #: / Expiration Date:
License/Registration Type and #: / Expiration Date:
License/Registration Type and #: / Expiration Date:
DEA# (M.D./D.O./ARNP): / NPI Number: / Board Certified?:
Yes No / Board Eligible?:
Yes No
Do you have a private practice? / Yes No / If Yes, provide a copy of your business license.
Has your professional registration license ever been suspended or revoked? / Yes No
If Yes, please explain:
EMPLOYMENT RECORD

Please list your employment history beginning with your MOST RECENT position. Use additional sheets if necessary.

Company/Organization: / Phone Number:
Address (include Complete Mailing Address, City, State, & Zip Code: / Supervisor’s Name:
Dates Employed:
From: To: / Position:
Duties:
Reason for Leaving: / Hours per week: / May we contact? Yes No
(We may contact if left blank)
Company/Organization: / Phone Number:
Address (include Complete Mailing Address, City, State, & Zip Code: / Supervisor’s Name:
Dates Employed:
From: To: / Position:
Duties:
Reason for Leaving: / Hours per week: / May we contact? Yes No
(We may contact if left blank)
Company/Organization: / Phone Number:
Address (include Complete Mailing Address, City, State, & Zip Code: / Supervisor’s Name:
Dates Employed:
From: To: / Position:
Duties:
Reason for Leaving: / Hours per week: / May we contact? Yes No
(We may contact if left blank)
Company/Organization: / Phone Number:
Address (include Complete Mailing Address, City, State, & Zip Code: / Supervisor’s Name:
Dates Employed:
From: To: / Position:
Duties:
Reason for Leaving: / Hours per week: / May we contact? Yes No
(We may contact if left blank)
AUTHORIZATION TO CONTACT REFERENCES
I, / hereby give Community Services Institute permission to
contact the references listed below for the purpose of verifying job position and performance. I authorize Community Services Institute to contact my former employers and authorize my former employers to release information pertaining to my record, my work habits, and my work performance while in their employ.

Signature:

Please provide the names of 3 supervisory and 2 professional references that are relevant to previous employment experiences and you have known for at least one year.

Reference Name: / Relationship/Affiliated By:
Company/Agency:
Phone Number(s): / Email Address:
Reference Name: / Relationship/Affiliated By:
Company/Agency:
Phone Number(s): / Email Address:
Reference Name: / Relationship/Affiliated By:
Company/Agency:
Phone Number(s): / Email Address:
Reference Name: / Relationship/Affiliated By:
Company/Agency:
Phone Number(s): / Email Address:
Reference Name: / Relationship/Affiliated By:
Company/Agency:
Phone Number(s): / Email Address:
CERTIFICATION AND UNDERSTANDING

Please read carefully the following statements and agreement before signing and submitting.

Unsigned applications cannot be considered.

I certify that the information contained in this application is correct to the best of my knowledge, and that any material misrepresentation is grounds for rejection of my application for employment or dismissal from employment.
I certify that I am a U.S. citizen or otherwise lawfully authorized to work in the United States.
I understand that if I am offered employment, I will have to undergo a criminal background check.
I certify that I am not legally excluded from participation as a provider or vendor in any Federal or State healthcare program.
I authorize investigation of all statements contained in this Employment Application as may be necessary in arriving at an employment decision.
I authorize Community Services Institute to solicit information regarding my previous employment, education, character, and general reputation, and I hereby release all persons and entities from all liability arising from the information they may provide.
I understand that all company property, including intellectual property and software, must be returned and any indebtedness to the company must be paid on or before my last day of my employment. I authorize the company to deduct from my paycheck the necessary amount to satisfy any unpaid obligations or in the event there are not sufficient funds from my paycheck, I agree to pay the debt upon request.
I hereby understand and acknowledge that any employment with Community Services Institute is of an “at will” nature, which means that the Employee may resign at any time and the Employer may discharge the Employee at any time, with or without cause. It is further understood that this “at will” employment relationship may not be changed by any statement, conduct, or written document, unless such change is specifically acknowledged in writing by both an authorized Executive of Community Services Institute and the Employee.
I understand that nothing contained in this application or in the interview and selection process is intended to create an express or implied contract of employment.

Applicant’s Signature Date

Applicants for employment are considered without regard to race, creed, color, religion, sex, sexual orientation, gender identity, marital status, genetic information, national origin, age and disability, military or veteran status, Vietnam Era Veteran, or being a member of the Reserves or National Guard. It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment. An employer who violates this law shall be subject to criminal penalties and civil liability.