Points of Origin, LLC Personnel Application Form

Personnel Application

Please complete the form below to apply for a position with us.
Full Name*

First NameMiddle NameLast Name
Date of Birth*

DayMonthYear
Social Security Number
NPI # (for clinicians)
License # & State (for clinicians)
Current Address*

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Email Address*
Phone Number*
Format: (000) 000-0000.
Desired start date

DayMonthYear
Applying for Position*
Which internship/ orientation cycle are you applying for?*
Year*
Select all that currently apply.

I expect to complete my master's program in the next three months at an accredited college/ university.I have completed my master's program at an accredited college/ university or will in the next 6-12 months.I have completed my master's program at an accredited college/ university or will in the next 12-18 months.I have scheduled my licensure exam.I am currently licensed/ intend to become licensed as an LPCA in the state of South Carolina within in the next 6 months.I am currently/ intend to become licensed as an LPC in the state of South Carolina.I am interested in licensure supervision (LPC/LPCS).
When did/will you complete your master's degree?*
Desired Salary
Are a citizen of the United States?*
Are you authorized to work in the US?
Emergency Contacts Please use this section to provide a list of two emergency contacts.
Emergency Contact*

Full nameRelationshipPhone numberCompany
Emergency Contact*

Full nameRelationshipPhone numberCompany

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Previous employment Please use this section to provide information about your previous employment starting with your current or most recent job.

Note: History is required. If you are a student/ applying for an internship and do not have prior employment, please complete this section with experiences you feel may help you be successful in the position you are applying for.
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Employment details*

CompanySupervisorPhone numberEmailJob title
Company Address*

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Employment start date*

MonthDayYear
Employment end date*

MonthDayYear
Responsibilities*
Reason for leaving*
Employment details*

CompanySupervisorPhone numberEmailJob title
Company Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Employment start date*

MonthDayYear
Employment end date*

MonthDayYear
Responsibilities*
Reason for leaving*

Education Please use this section to provide information about your previous education including the qualifications/certificates your have gained.
High School/College*

School nameStart dateFinish date
Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Subjects and grades*
University*

School nameStart dateFinish date
Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Subjects and grades*
Other

School nameStart dateFinish date
Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Subjects and grades

Refrences Please use this section to provide a list of two professional references (not family members).
Reference 1:*

Full nameRelationshipPhone numberCompany
Address
Reference 2:*

Full nameRelationshipPhone numberCompany
Address

Criminal record Due to the nature of the posts within MBS Care, they may be exempt from the Rehabilitation of Offenders Act 1974 (exception Orders1975). If the post applied for requires a Disclosure as indicated on the front page, you should disclose information of all spent and unspentconvictions as well as details of any cautions, reprimands or final warnings, whether in the UK or abroad.
Do you have any criminal convictions or are you currently the subject of any police investigation in the UK or abroad? *

YesNo
Are you currently the subject of any investigation or proceeding by anybody having regulatory functions in relation to health and social care professionals including a regulatory body abroad? *

YesNo
Have you ever been disqualified from the practice of a profession or required to practice it subject to specified limitations following a fitness to practice investigation by regulatory body abroad? *

YesNo
If you have answered YES to any of the questions above, please give further details.
I certify to Points of Origin, LLC that the information used to complete this application is true and complete to the best of my knowledge, and I consent Points of Origin, LLC in processing personal data about me for purposes related to my employment in line with the DATA PROTECTION ACT, 1998. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my refusal or termination of employment.*

I agree