Employment Application

Employment Application

* Please fill out this form in its entirety. Place "N/A" where appropriate.
Position Applying For
Date of Application

MonthDayYear
Date
Do you have one of the following licenses: Licensed Social Worker; Licensed Independent Social Worker; Licensed Professional Counselor or; Licensed Professional Clinical Counselor?
Name

First NameMiddle NameLast Name
Other Names

Maiden NameAlias/Nickname
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date Available to Begin working

MonthDayYear
Are you a U.S. Citizen?
If no, are you authorized to work in the US?
Have you ever worked for ATLC?
If so, when?

Employment History

Please start with most recent.
Would you like to submit a resume in lieu of typing your employment history below?
File Upload

Cancelof
- Company Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Job Title
- Supervisor
- Starting Salary
- Ending Salary
- Job Responsibilities
- From
  
  MonthDayYear
  Date
- To
  
  MonthDayYear
  Date
- Reason for Leaving
- May we contact your supervisor for a reference?
- Company Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Job Title
- Supervisor
- Starting Salary
- Ending Salary
- Job Responsibilities
- From
  
  MonthDayYear
  Date
- To
  
  MonthDayYear
  Date
- Reason for Leaving
- May we contact your supervisor for a reference?
- Company Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Job Title
- Supervisor
- Starting Salary
- Ending Salary
- Job Responsibilities
- From
  
  MonthDayYear
  Date
- To
  
  MonthDayYear
  Date
- Reason for Leaving
- May we contact your supervisor for a reference?

Availability

If you cannot work Afternoons, Midnights or Weekends Do Not Apply!

Please list what day and times you are available to work below. If you cannot work Afternoons, Midnights or Weekends Do Not Apply!

References

Please list three references from individuals who are NOT related to you!
Reference 1 Name:

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Reference 2 Name:

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Reference 3 Name:

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Military Service
Have you ever served in the military?
Branch
Are you on active duty?
Date of Discharge

MonthDayYear
Date
Type of Discharge
If other than honorable, explain:

Education Background