Employment Application Form - Talbot Child Psychology, LLC

Talbot Child Psychology, LLC

Employment Application
Employment Application TCP is an equal opportunity employer. Applicants will be considered regardless of race, color, national origin, religion, gender, age, marital, or veteran status; medical condition, disability; or any other legally protected status. Equal access to the hiring process, services, and employment is available to all individuals. Applicants requiring accommodations to the application and/or interview process should contact the Human Resource Representative. Each question should be answered completely and accurately. No action will be taken on this application until all questions have been answered and the application has been signed and dated. Verification of eligibility to work in the U.S. will be required if an employment offer is made.

Section I

Basic identification and Contact Information
Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
E-mail

Confirmation Emailexample@example.com

Section II

About the Position and General Qualifications
Position(s) applying for
Please refer to job advertisement
Wage expectations
Hourly Rate
Have you ever been employed in the healthcare sector?

YesNo
Previous Healthcare Sector Position (if you responded yes above)
Are you over the age of 18?

YESNO
Are you eligible to work in the United States?

YESNO
Are you fluent in a foreign language?

YESNO
If yes, what language(s)?

Section IV

Education
What are your formal Education Degrees?
Example RT, B.Sc, MBA, e.t.c.
Highest level of education completed:

Please complete the appropriate sections

	Name & Location of School	Number of Years Attended	Did You Graduate?	Degree or Certification
GED / High School
Trade School
College
Graduate

Section IV

Work History
WORK HISTORY Please list your four most recent employers, list the most recent first. In lieu of completing Sections V through VIII, You may upload a Resume featuring all information listed within Sections V - VIII.
Will you be uploading a Resume featuring all required responses in Sections V through VIII?

YesNo

Section V

Employment History 1
Employer #1
Employer's Name (Most current)*
Address & location of business*
Your title*
May we contact this employer?*

YESNO
Supervisor's name*
First and Last Name
Phone number*
Start date*

MonthDayYear
End date

MonthDayYear
Wages START:*
Salary or Hourly*
Wages END:*
Salary or Hourly*
Work performed:*
Reason for leaving*

Section VI

More on Work History
Employer #2
Employer's Name (Second most recent)*
Address & location of business*
Your title*
May we contact this employer?*

YESNO
Supervisor's name*
First and Last Name
Phone number*
Start date*

MonthDayYear
End date

MonthDayYear
Wages START:*
Salary or Hourly*
Wages END:*
Salary or Hourly*
Work performed:*
Reason for leaving*

Section VII

Work History Continued
Employer #3
Employer's Name (Third most recent)
Address & location of business
Your title
May we contact this employer?

YESNO
Supervisor's name
First and Last Name
Phone number
Start date

MonthDayYear
End date

MonthDayYear
Wages START:
Salary or Hourly
Wages END:
Salary or Hourly
Work performed:
Reason for leaving

Section VIII

Work History
Employer #4
Employer's Name (Fourth most recent)
Address & location of business
Your title
May we contact this employer?

YESNO
Supervisor's name
First and Last Name
Phone number
Start date

MonthDayYear
End date

MonthDayYear
Wages START:
Salary or Hourly
Wages END:
Salary or Hourly
Work performed:
Reason for leaving

Section IX

Military and other Information
ADDITIONAL INFORMATION RE - Military and other Information
Do you have a U.S. military service record?*

YESNO
If yes, branch of service*
Discharge date and rank*
List any additional information you would like us to consider:
List job-related accomplishments, projects, and awards. (Exclude information that would reveal race, color, national origin, religion, gender, age, marital, or veteran status; medical condition, disability; or any other legally protected status.)

Section References

About your Current Employment and other Information
REFERENCES List three professional references, (business or work, not relatives) that you have known for at least one year. List at least one previous supervisor.
1. Full Name*

First NameLast Name
Company*
Best phone number to reach them*
Years acquainted*
Relationship*
2. Full Name*

First NameLast Name
Company*
Best phone number to reach them*
Years acquainted*
Relationship*
3. Full Name*

First NameLast Name
Company*
Best phone number to reach them*
Years acquainted*
Relationship*
AUTHORIZATION I understand that Talbot Child Psychology, LLC is making no employment offer at this time. I certify that the information in this application is correct to the best of my knowledge. I understand that any misrepresentation or omission of any fact in my application, resume, or any other materials, or during interviews is grounds for disqualification from further consideration for employment or for termination, if employed. I authorize Talbot Child Psychology, LLC to contact any company, institution, or individual it deems appropriate to investigate my employment history, character, qualifications, credit history, driving record, and other relevant information, if job-related. I give my full consent for all contacted individuals, including former employers, to provide information concerning this application, and I waive my right to bring any cause of action against these individuals for any and all liability for damages arising from furnishing the requested information to Talbot Child Psychology, LLC. I acknowledge that a facsimile and/or photocopy of this form is as valid as the original. Pre-employment testing may be required (drug testing, background checks, physical examinations, motor vehicle checks).Testing may be applicant or employer paid based on the employer.I understand that any offer of employment may be withdrawn if drug tests are positive and/or if a condition is discovered for which no reasonable accommodation can be made. I understand that this application is current for 60 days. At the conclusion of this time, if I have not heard from Talbot Child Psychology, LLC and still wish to be considered for employment, it will be necessary to complete a new application. I understand that if hired, employment is at-will, regardless of the employer, and may be terminated by myself, the employer or Talbot Child Psychology, LLC at any time, with or without cause or notice, for any reason or no reason.
By entering your name, you agree to accept the terms of the above document with an electronic signature.*

I agreeI do not agree
You must agree to accept the terms of the document in order to submit an application.
Print your Full Name*
Date*

MonthDayYear
Date
Upload your resume, click Choose File

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Upload optional cover letter, click Choose File

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Signature

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Talbot Child Psychology, LLC

Section I

Section II

Section III

Section IV

Section IV

Section V

Section VI

Section VII

Section VIII

Section IX

Section References