Job Application Form
Please Fill Out the Form Below to Submit Your Job Application!
Applicant Information
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
Employment Position
Position to Apply
Please Select
Clinical Supervisor
Mental Health Therapist
Qualified Behavior Health Specialist
Earliest Possible Start Date
-
Month
-
Day
Year
Date
How did you hear about this position?
What days are you available for work?
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
What hours or shift are you available to work?
Preferred Interview Date
Do you have reliable transportation to and from work?
Salary desired:
per hour
Personal Information
Have you ever applied to or worked for this agency before? If yes, when?
Are you 18 years of age or older?
Are you a U.S. citizen or approved to work in the United States?
yes
no
What document can you provide as proof of citizenship or legal status?
Will you consent to a mandatory controlled substance test?
yes
no
Have you ever been convicted of a criminal offense (felony or misdemeanor)?
yes
no
If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense.The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)
Job Sills/Qualifications
Please list below the skills and qualifications you possess for the position for which you are applying:
(Note: Peter James Development & Independent Living, Inc. complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.)
Education and Training High School
High School(s) Attended:
*
College/University or Vocational School/Specialized Training
*
College/University or Vocational School/Specialized Training
*
Military:
Are you a member of the Armed Services?
What branch of the military did you enlist?
What was your military rank when discharged?
How many years did you serve in the military?
Previous Employment
Employer Name:
Job Title:
Supervisor Name:
Employer Address:
City, State and Zip Code:
Employer Telephone:
Dates Employed:
Reason for Leaving:
References:
College/University or Vocational School/Specialized Training
*
At-Will Employment
The relationship between Peter James Development & Independent Living, Inc. is referred to as "employment atwill." This means that your employment can be terminated at any time for any reason, with or without cause,with or without notice, by you or the Peter James Development & Independent Living, Inc. No representative ofPeter James Development & Independent Living, Inc. has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that youacknowledge that no oral or written statements or representations regarding your employment can alter your at‐ will employment status, except for a written statement signed by you and either our Chief Operations Officer orthe Company's Executive Director/ Chief Executive Officer.
Signature
Date
-
Month
-
Day
Year
Date
Cover Letter
Please do not exceed 200 words.
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*
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