Genesis Behavioral Services Application

GENESIS BEHAVIORAL SERVICES
25701 N Lakeland Blvd. Suite 403 Lakeland Medical Building Euclid, OH 44132
APPLICATION
NOTICE TO APPLICANTS: This application form is intended for use in evaluating your qualifications for employment/contract. False or misleading statements on this form or during the interview are grounds for terminating the applicant process; or, if discovered after employment/contract, terminating employment/contract. You may provide additional information on a separate sheet of paper. If you need assistance in completing this form due to a disability, please notify us. Additional testing of job-related skills and drug testing may be required prior to employment/contract. After an offer of employment/contract, you may be required to submit to a drug screening.
EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER
Genesis Behavioral Services, Inc. is an Equal Opportunity Employer. All applicants will be considered without regard to age, color, national origin, religion, sex, or other protected status in accordance with applicable Federal and State employment opportunity laws.

EDUCATION

A transcript upon request must verify all education above a High School Diploma
Did you graduate from High School? *

Yes No
If No, did you receive a GED?

Yes No

Education *

	School Name /Location	Major	Graduated (Date)	Diploma or Degree	Credit Hours Earned
School 1
School 2
School 3

TRAINING/SKILLS/QUALIFICATIONS
List any professional or occupational license, registration, or certifications you currently hold (i.e. LPC, NP, LISW Licensure). If licensure or certification is required for a position vacancy, a copy of the document must accompany the application. If you have training in an area, which you feel is relevant to the position for which you are applying, please include (do not include training gained as part of your education as described above).
Do you hold a professional license? *

Yes No
If yes, Type of License?
License Number
Expiration
If applying for an admin position please list proficiencies below:
In the area below, please describe any additional information or special qualifications you have for the position(s) requested. Include MS,software applications, etc.

EMPLOYMENT

Starting with your current or most recent job, list your last jobs in order. Do not omit a job. Please account for all periods of unemployment, including military experience. Include any volunteer work that relates to the position for which you are applying.
Start Date *
End Date *
Company Name/Address *
Phone Number *

Area Code Phone Number
Name & Title of Supervisor *
Starting Position *
Ending Position *
Description of Duties *
Starting Pay
Ending Pay
Reason for leaving *
Start Date
End Date
Company Name/Address
Phone Number

Area Code Phone Number
Name & Title of Supervisor
Starting Position
Ending Position
Description of Duties
Starting Pay
Ending Pay
Reason for leaving
Start Date
End Date
Company Name/Address
Phone Number

Area Code Phone Number
Name & Title of Supervisor
Starting Position
Ending Position
Description of Duties
Starting Pay
Ending Pay
Reason for leaving
Start Date
End Date
Company Name/Address
Phone Number

Area Code Phone Number
Name & Title of Supervisor
Starting Position
Ending Position
Description of Duties
Starting Pay
Ending Pay
Reason for leaving
REFERENCES

List three (3) professional non‐relative references who are familiar with your qualifications and actual work history and ability.

REFERENCES *

	Name	Occupation/Relationship	Years Known	Phone Number
Reference 1
Reference 2
Reference 3

ATTESTATION
FILL IN THIS STATEMENT IF YOU HAVE RESIDED IN THE STATE OF OHIO FOR THE LAST FIVE (5) YEARS.

I, {name}, hereby attest that I have not been convicted of or plead guilty to a disqualifying offense under the jurisdiction of Ohio or any other similar jurisdiction of the United States. I further attest that I have not been convicted for any offense that has been expunged or sealed.

I agree that I will notify my employer Genesis Behavioral Services, Inc. within fourteen (14) days if, while employed/contracted by GBS, Inc. I am formally charged with, am convicted of, pleaded guilty to a disqualifying offence. I understand that failure to make the notification may result in termination of employment/contract.

I attest that I have been a resident of Ohio for the five (5) year period immediately prior to the date upon which a criminal records check is requested. I understand the GBS, Inc. may request the Bureau of Criminal Identification and Investigation obtain information from the Federal Bureau of Investigation as part of the criminal records check.

I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.
Signature

Clear
Date

Month Day Year
Date
OR..
FILL IN THIS STATEMENT IF YOU "HAVE NOT" RESIDED IN THE STATE OF OHIO IN THE LAST FIVE (5) YEARS.

I, {name}, hereby attest that I have not been convicted of or plead guilty to a disqualifying offense. I further attest that I have not been convicted for any offense that has been sealed.

I agree that I will notify my employer Genesis Behavioral Services, Inc. within fourteen (14) days if, while employed/contracted by GBS, Inc. I am formally charged with, pleaded guilty to or am convicted of any charge under the jurisdiction of Ohio or any other similar jurisdiction of the United States whether those records have been expunged or sealed.

I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.
Signature

Clear
Date

Month Day Year
Date
25701 N Lakeland Blvd. Suite 403

Lakeland Medical Building Euclid, OH 44132

CRIMINAL CONVICTION DISCLOSURE

A criminal conviction will not necessarily disqualify an applicant from employment/contract. Applications with incomplete responses in this section will be considered unresponsive and discarded without notification to the applicant. The applicant must provide accurate and truthful information in all sections of this document. Falsification of any information provided, either by commission or omission, is grounds for rejection of the application and or termination of employment/contract. FBI and BCII background checks will be performed after a job offer is made.
Have you ever been convicted of a crime? *

Yes No
If all of your convictions were sealed (expunged), you may answer "no" to this question. If you answered yes, complete the table below for each conviction regardless of the date of the conviction. The burden of accuracy rests with the applicant. We highly recommend that you go to the jurisdiction(s) of your conviction(s) and secure a copy of your record. Disclosure of inaccuracies will be treated as a falsification.

Please enter: Date of Conviction | Legal Description of Conviction | Criminal Code of Conviction

	Date of Conviction	Legal Description of Conviction	Criminal Code of Conviction
Conviction
Conviction

Legal Description of Conviction

dated Please read the following statements carefully before signing this application. Only those applications that are signed andareconsidered valid. If you have any questions regarding this statement, please ask before signing.

I certify that I have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that the answers given by metrueand correct to the best of my knowledge and ability. I understand that any omission (including any misstatement) of material fact on this are application or any document used to secure employment/contract can be grounds for rejection of application or, if I am employed/contracted by GBS, Inc., terms for my immediate discharge from GBS, Inc.

I understand that employment/contract at this company is "at-will", which means that either the company or I can terminate the employment/contract relationship at any time, with or without prior notice, and for any reason not prohibited by statue. All employment/contract is continued on that basis.

I certify that all answers and statements I have made on this application are accurate and complete without omissions. I understand that any false information will be grounds for refusal to hire or for immediate discharge if I am employed/contracted. I authorize the company to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies or organizations and law enforcement agencies to give complete information and records regarding my employment/contract, education, character, and qualifications and hereby release any said persons. Schools, companies or organizations and law enforcement agencies from any liability for any damage whatsoever for providing this information.

I understand that the use of illegal drugs' and alcohol is prohibited during employment/contract. If company requires, I am willing to submit to drugtesting to detect the use of illegal drugs prior to and during employment/contract.

I will be responsible for familiarizing myself with all rules and regulations of the company as they presently exist or are modified.

I also understand that no representative of the company has any authority to enter into my employment/contract agreement for any specified period of time, or to assure me of any future position, benefits, or terms and conditions of employment/contract, except as specifically stated in a current written agreement signed by the President of Company.
BY PRINTING YOUR FIRST, LAST NAME AND DATE IN THE FIELDS BELOW, YOU AGREE, ACKNOWLEDGE, CERTIFY, AUTHORIZE, AND ATTEST
REGARDING ALL CONTENTS OF THIS APPLICATION.

I have read, understand, and agree with the above:
Print Name *
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

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GENESIS BEHAVIORAL SERVICES

APPLICATION

EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER

TRAINING/SKILLS/QUALIFICATIONS

ATTESTATION

BY PRINTING YOUR FIRST, LAST NAME AND DATE IN THE FIELDS BELOW, YOU AGREE, ACKNOWLEDGE, CERTIFY, AUTHORIZE, AND ATTEST