Application for Employment April 2023

This application must be completed fully in order for you to be considered for employment. You will also be asked to certify that all information contained in this application is correct and authorize any agent or employee of Bridge Health to verify this information and to release it to anyone within Bridge Health who may wish to consider me for an appointment. Intentionally providing false information on this form or attachments is a violation of state law. Applications submitted electronically, via e-mail or similar media, are not valid unless you enter your name in the designated signature field below.

If you are unable to complete the online application you may download the Employment Application in Adobe format (.pdf). Once completed, you can either submit it in person at 501 Mize Street in LaFayette, GA, or send it by electronic mail to jobs@lmcs.org.

In order that Bridge Health can best evaluate your qualifications, you must give permission for Bridge Health to investigate all references and to secure reference check information in order to arrive at a hiring decision. You authorize all persons, institutions, organizations, and companies to furnish any and all information sought and waive any legal requirement to provide notice to you regarding reports, records, or information given or received in accordance with this authorization. By agreeing, you hereby release and hold harmless Bridge Health, its agents, employees, and assigns from any claim of liability you may have against it and /or their employees for decisions, even if adverse, arising out of information received in response to the reference check. You authorize any person or entity to whom this reference check is presented to release any information required to Bridge Health, its agents, employees, or assigns.

If an employment offer is extended you may be required to complete a pre-employment drug test. You are advised that if you are offered employment the offer will be withdrawn and you will be disqualified from employment at Bridge Health for a period of two (2) years from the date of testing or refusal to test if you:

· expressly decline to submit to testing; failure to appear for drug testing as directed; engage in conduct that clearly abstracts the testing process;

· fail to provide, adequate urine for drug testing without a valid medical explanation: provide a urine sample determined by the testing laboratory to have been adulterated;

· or, test positive for the use of an illegal drug(s).

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

County*

Are you Bi-lingual or Multi-Lingual and if so, what languages do you fluent in?*

YesNo

Languages fluent in:

Are you fluent in American Sign Language (ASL)?*

YesNo

Do you have a family member who is currently employed or is a sub-contractor with Bridge Health?*

YesNo

If yes, Please provide their name and department/program:

Daytime Phone Number

Format: (000) 000-0000.

Mobile Phone Number*

Format: (000) 000-0000.

Electronic Mail Address*

Ethnicity*

Are you 21 or older?*

YesNo

Gender*

MaleFemale

Preferred method of contact:*

EmailDaytime PhoneMobile Phone

Are you a United States Citizen?*

YesNo

Are you an alien authorized to work in the United States of America?

YesNo

Have you ever been dismissed from any State of Georgia government position or Community Service Board?*

YesNo

If "Yes" above, please provide details (when/where)

Job Title Sought:*

Referred By:

Salary Expectations*

Which work population are you seeking to work in?*

Are there are days/hours you cannot work? If so, please list below.

What type of employment are you interested in?*

Have you ever been employed with this agency in the past?*

YesNo

If you answered yes above, please list when, where, and your supervisor.

Are you clinically licensed in the state of Georgia as a LPC, LCSW, LMCF, or other?*

YesNo

If you answered yes above, please list your Georgia state licensing below.

Are you clinically licensed in another state?

YesNo

If you answered yes above, please list your licensing below.

Have you been convicted of a drug-related criminal offense?*

YesNo

If you you answered yes above, has it been more than three (3) months since your first conviction, or more than five (5) years since a second/subsequent conviction (O.C.G.A. 45-23 et. Seq.).

YesNo

Please specify the counties in which you are available to work:*

I understand that any offer of employment is contingent upon passing a drug test?*

YesNo

Skills - Check any that apply to you*

Do you have a valid Georgia Drivers' License?*

YesNo

If you have a drivers license from a state besides Georgia, please select below

Drivers License Number*

Drivers License Expiration*

Date

Commercial Driver's License (if applicable)

Current or Last Employer*

Current or Last Employer - Your Title*

Current or Last Employer Address

Street Address

Street Address Line 2

CityState

Zip Code

Date of Employment (Start)*

Date

Date of Employment (To)*

Date

Annual Salary (Numeric)*

# and type employees supervised (if applicable)

Supervisors Name and Title*

Supervisor's Phone Number:*

Format: (000) 000-0000.

May we contact employer?*

YesNo

Reason for Leaving:*

Describe in detail your job duties and the average percent of work time you spend daily on each duty.*

Do You Have Another Previous Employer to List?*

YesNo

Next to Last Employer

Next to Last Employer - Your Title

Next to Last Employer Address

Street Address

Street Address Line 2

CityState

Zip Code

Date of Employment (Start)

Date

Date of Employment (To)

Date

Annual Salary (Numeric)

# and type of employees supervised (if applicable)

Supervisors Name and Title

Supervisor's Phone Number:

Format: (000) 000-0000.

May we contact employer?

YesNo

Describe in detail your job duties and the average percent of work time you spend daily on each duty.

Reason for Leaving:*

Do You Have A Third Previous Employer to List?*

YesNo

Third Employer

Third Employer - Your Title

Third Employer Address

Street Address

Street Address Line 2

CityState

Zip Code

Date of Employment (Start)

Date

Date of Employment (To)

Date

Annual Salary (Numeric)

# and type of employees supervised (if applicable)

Supervisors Name and Title

Supervisor's Phone Number:

Format: (000) 000-0000.

May we contact employer?

YesNo

Describe in detail your job duties and the average percent of work time you spend daily on each duty.

Reason for Leaving:

Please Explain Any Gaps in Employment History

Professional Work Reference One Contact Name*

First NameLast Name

Professional Work Reference One Address

Street Address

Street Address Line 2

CityState

Zip Code

Professional Reference One Phone*

Format: (000) 000-0000.

Professional Reference One Email

example@example.com

Professional Work Reference Two Contact Name*

First NameLast Name

Professional Work Reference Two Address

Street Address

Street Address Line 2

CityState

Zip Code

Professional Reference Two Phone*

Format: (000) 000-0000.

Professional Reference Two Email

example@example.com

Professional Work Reference Three Contact Name*

First NameLast Name

Professional Work Reference Three Address

Street Address

Street Address Line 2

CityState

Zip Code

Professional Reference Three Phone*

Format: (000) 000-0000.

Professional Reference Three Email

example@example.com

High School or Equivalent (GED)?*

YesNo

Attend Vocational/Business School?

YesNo

Vocational/Business School

Number of Months Attended

Field of Study

Date Completed

Date

Attended College?*

YesNo

Most Recent College Attended

Major

Degree Achieved

Date Degree Completed

Date

Do you have a Second College to Add?

YesNo

Next to Last College Attended

Major

Degree Achieved

Date Degree Completed

Date

Do you have a Third College to Add?

YesNo

Second to Last College Attended

Major

Degree Achieved

Date Degree Completed

Date

I give permission for the representative of LMCS to contact my current employer for a reference.*

YesNo

I give permission for the representative of LMCS to contact my past employers as shown on my job application and those listed below for employment references.*

YesNo

You may upload a resume and/or cover letter here.

Browse Files

Applicant Signature - Signing your name below signifies that you agree with the certification request above.

Enter the message below as it's shown. This helps prevent spam.*

Bridge Health Employment Application

Equal Employment Opportunity Monitoring Information

Employment Eligibility

Type of Work Sought

Drivers License Information

Work History

Work References - Please List Three (3) Professional Work References

Formal Education

Authorization for Release of Reference Information

Resume/Cover Letter

Certification