The Aya Center Application Form

Application for Employment:

All statements and questions are to be completed; the answers will be confidential
Thank you for your interest in employment with The Aya Center. The Center provides a complete spectrum of behavioral health care. This application may used to apply for positions within our
organization.

The Aya Center is an equal opportunity employer and does not discriminate against otherwise qualified applicants on the basis of race, color, creed, religion, ancestry, age, sex, marital status, national origin, disability or handicap or veteran status.

Conditions of employment are stated at the end of this form. Please read carefully before you sign this application (Application must be completed in full even if attaching a resume or Curriculum Vitae [CV]).

At the time of offer and acceptance the following information must be submitted, without this information a start date cannot be scheduled.
- A valid driver’s license along with proof of current automobile insurance with expiration date.
- Two forms of proof that establish work eligibility as specified by the second page of the Federal I-9 form. (e.g.: Social Security Card, Passport or Birth Certificate)
- Evidence of attained education level: i.e. high school diploma or GED, College Degree with transcript, professional licenses and any applicable certifications.
If certified in any of the following, please submit a copy of your card / certification:
1. CPR
2. First Aid
3. NCI Plus
4. Bloodborne Pathogens
Sincerely,

Human Resources Services

Personal Information:
Full Name*

First NameMiddle NameLast Name
Birth Date*

MonthDayYear
SSN*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

List all home addresses for the past ten years

	Street	City/Town	State	Zipcode
1
2
3
4

Phone Number*

Area CodePhone Number
E-mail*

Employment Desired:
Position(s) Applying For*
Salary Expectations*
Type of Work Preferred*

Full TimePart TimeRegularTemporary
Date You Can Start*

MonthDayYear
Location(s) Preferred *

Work/Volunteer Experience

Give your full employment record - start with your current or most recent employment. Use additional sheets if necessary.
Current or last Employer:
Supervisor's Name & Title:
Type of Business
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
End Date

MonthDayYear
Start Date

MonthDayYear
Job Title:
List major duties in order of importance in the job:
Starting Salary
Ending/Current Salary
Reason for Leaving?
Current or last Employer:
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor's Name & Title:
Type of Business
Phone Number

Area CodePhone Number
End Date

MonthDayYear
Date
Start Date

MonthDayYear
Date
Job Title:
List major duties in order of importance in the job:
Starting Salary
Ending/Current Salary
Reason for Leaving?
Current or last Employer:
Phone Number

Area CodePhone Number
Supervisor's Name & Title:
Address

Street Address

Street Address Line 2

CityState

Zip Code
Type of Business
End Date

MonthDayYear
Date
Start Date

MonthDayYear
Date
Job Title:
List major duties in order of importance in the job:
Starting Salary
Ending/Current Salary
Reason for Leaving?

Military Experience

If you are or have been in service, please fill out the following:
Branch:
Nature of Duties
Highest rank or grade:
Terminal rank or grade:
Date Entered:

MonthDayYear
Date
Date Discharged

MonthDayYear
Date

Education:

If not obtained, please insert N/A*

	Name & Location of School	From/To Month/Year	Graduate? If so, please enter date	Credit Hours Receieved	Degree or Diploma recieved	Major Subjects
High School
Trade/Business School
College or University
Graduate or Professional School

Professional License & Certifications

Insert N/A in blank spaces please.*

	License/Certificate Number	Field or Specialty	Agency & State Issued By:	Expiration Date
1.
2.
3.
4.
5.

Summarize any special skills and training not listed above:*
Please type your NPI number below. Type n/a if this does not apply to you.*
Please type your CAQH number below. Type n/a if this does not apply to you.*
Membership in professional or job-related organizations (Please exclude racial, religious and nationality groups):*
Publications, professional licenses or special honors or awards:*

Professional References:

Please complete the following information for three professional references. To aid in your potential employment, please ensure that all information is accurate and current. To assist The Aya Center in their efforts to locate and consult the listed references, please provide any known alternative numbers and the best possible times to reach the reference. Thank You.
Name*
Name of Reference
Title*
Company Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Alt. Telephone
Name*
Name of Reference
Title*
Company Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Alt. Telephone
Name*
Name of Reference
Title*
Company Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Alt. Telephone

Cover Letter & Resume (optional):
Cover Letter

Upload a File

Cancelof
Resume*

Upload a File

Cancelof

Submit Application:
The Aya Center is an Equal Opportunity Employer and selects employees regardless of race, color, religion, sex, national origin, age, ancestry, physical or mental handicap, or veteran status, under Local, State or Federal Equal Opportunity Laws.
1. I understand and agree that any material misrepresentation or omission of fact in my application will render this application void and may result in refusal to employ me or, if hired, termination of my employment.
2. I authorize The Aya Center to investigate my work history, to verify all data given in my application for employment, related documents, or interviews, and to contact my former employers, references, reporting agencies, and any other persons. I recognize and acknowledge that any such information may be the basis for declining the employment applied for or, if hired, for terminating the employment. I request and authorize all persons so contacted to furnish the information so requested and, in consideration for so doing, hereby release any persons furnishing or receiving such information from all liability which might arise out of the communication so made or the information so furnished. I agree to complete a release for The Aya Center to conduct a Criminal Background Check, a Department of Motor Vehicles Check, North Carolina Health Care Personnel Registry Check and the OIG and GSA/EPLS check, and understand that an employment offer will be contingent on a review of this background check, pursuant to The Aya Center policies and procedures.
3. I understand that I may be required to take a medical examination or a drug screening by a qualified physician or a laboratory at the discretion of The Aya Center, after a conditional offer of employment has been made by The Aya Center.
4. I agree that, if given a conditional offer of employment, I will provide, and authorize any physician or hospital to release, any information, which may be necessary to determining my ability to perform the duties of the job for which I have been offered employment.
5. I understand and agree that any employment offered pursuant to this application will be at-will, terminable by either party at any time with or without reason, with or without notice, and with or without procedural formality or progressive discipline. I understand and agree that no representation, written or oral, express or implied, including without limitation those contained in any employment manuals, handbooks or information booklet that may be distributed to me during the course of my employment, shall form a contract between me and The Aya Center so as to alter the at-will character of my employment. I further understand and agree that no person at The Aya Center, other than the CEO, has any authority to make any promise or representation to alter the at-will character of my employment. I understand that this is an application for employment and no employment contract is offered or implied, and that The Aya Center is bound by the North Carolina laws regarding Employment at Will.
6. I understand and agree that, if offered employment, such employment shall be subject to the reasonable rules and
  regulations of The Aya Center as issued or changed at any time, without notification.
7. I understand and agree that The Aya Center may at times require overtime, holiday work, change of hours and/or days I am scheduled to work, or require me to work a schedule other than that for which I was originally hired, and I accept these as conditions of my continuing employment.
8. I understand and agree that The Aya Center may change my job title, assigned duties, wages, benefits, place of employment, and/or other conditions of employment at any time, and I accept these as conditions of my continuing
  employment.
9. I understand and agree that this is an application for employment, and that no employment contract is offered or implied.
I have read, understand and agree to the above conditions.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Application for Employment:

Personal Information:

Employment Desired:

Personal/General Information

Work/Volunteer Experience

Military Experience

Education:

Professional License & Certifications

Professional References:

Cover Letter & Resume (optional):

Submit Application: