It is the policy of Wilmington Mental Health, PLLC to provide equal employment opportunities to all applicants and employees without regard to any legally protected status such as race, color, religion, gender, national origin, age, disability, or veteran status.

Each question should be fully and accurately answered. No action can be taken on this application until all questions have been answered. Use blank paper if you do not have enough room on this application. Please print, except for signature sections. Please be aware that none of the questions are intended to imply preferences or discrimination based upon non-job-related information.

*Current licensure from a primary source will be required with verification via telephone, letter, website, computer printout, or official documents/transcripts from the appropriate institution and/or licensing board. 

Professional License/Certification Number

REFERENCES: (Most recent supervisory references. These will be contacted)

I certify that the information provide on this application is truthful and accurate. I understand that providing false or misleading information will be the basis for rejection of my application, or if employment commences, immediate termination.

I authorize Wilmington Mental Health, PLLC to contact former employers and educational organizations regarding my employment and education. I authorize my former employers and educational organizations to fully and freely communicate information regarding my previous employment, attendance, and grades. I authorize those persons designated as references to fully and freely communicate regarding my previous employment and education.

If an employment relationship is created, I understand that unless I am offered a specific written contract of employment signed on behalf of the company by its Director, the employment relationship will be "at-will." In other words, the relationship will be entirely voluntary in nature, | will have the full and complete discretion to end the employment relationship when I chose and for reasons of my choice. Similarly, my employer will have the right. Moreover, no agent, representative, or employee of Wilmington Mental Health, PLLC, except in a specific written contract of employment signed on behalf of the company by its Director, has the power to alter or vary the voluntary nature of the employment relationship.

I authorize investigation of all statements contained in this application. Further, I understand and agree that my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without previous notice.

I have carefully read the above certification and I understand and agree to its terms.

I authorize the company I worked for and/or the individual listed above to release information about me to Wilmington Mental Health PLLC.