New Growth Behavioral Health Employment Application

Application for Employment

New Growth Behavioral Health
Full Name*

First NameMiddle InitialLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail*
Phone Number*

Area CodePhone Number
Available start date:*

MonthDayYear
Do you have a valid driver's license?

YesNo
Are you authorized to work and remain in the United States?

YesNo
Are you registered with Commonwealth of Virginia Board of Counseling? If so what is your current qualification:
Have you ever been convicted of any violation of the law? (Exclude traffic violations) A conviction will not necessarily disqualify an applicant from the position sought.

YesNo
If Yes, Explain:
Education:
Are you a High School Graduate?

YesNo
High School Equivalency?

YesNo
Are you presently attending school?

YesNo
Type of Education
Name of Instiution
Field of Study
Type of Degree
Did you Graduate?

YesNo
Do you have additional education to enter?

YesNo
Additional Type of Education
Name of Instiution
Field of Study
Type of Degree
Did you Graduate?

YesNo
Position Desired
Position(s) applied for
Desired Work Schedule

Full-Time ONLYPart Time ONLY
When are you available to start work?
Salary
Employment History

Beginning with your present or most recent experience, account for all employment during the past ten (10) years. To elaborate, a supplemental sheet or resume may be attached, but cannot be substituted for a completed application. Include military service if applicable.
Name of Employer:
Job Title:
Phone Number

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Supervisor:
Ending Salary Per Month:
Date started

MonthDayYear
Date ended

MonthDayYear
Reason for Leaving:
Description of Duties:
Do you have additional employers to enter?

YesNo
Name of Employer:
Job Title:
Phone Number

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Supervisor:
Ending Salary Per Month:
Date started

MonthDayYear
Date ended

MonthDayYear
Reason for Leaving:
Description of Duties:
Inquiry may be made of your current and former employers/schools you attended.
May we contact your present employer?

YesNo
May we contact your former employers?

YesNo
How you ever been employed with this company?

YesNoIf yes, when?Other
Do you have any friends or relatives employed by this company?

YesNo
If yes, please provide their names and relationship to you.
Personal References
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business or Occupation
Phone Number

Area CodePhone Number
APPLICATION FORM WAIVER – PLEASE READ CAREFULLY

In exchange for the consideration of my job application by Fuzzy’s Family Kitchen, I agree that: Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, and regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements, and the like as they may exist from time to time, or other Company practices, shall serve to create an actual or implied contract of employment, or to confer any right to remain an employee of, or otherwise to change in any respect the employment-at-will relationship between it and the undersigned, and that relationship cannot be altered except by a written instrument signed by the President /General Manager of the Company. Both the undersigned and may end the employment relationship at any time, without specified notice or reason. If employed, I understand that the Company may unilaterally change or revise their benefits, policies and procedures and such changes may include a reduction in benefits.

I authorize investigation of all statements contained in this application. I understand that the misrepresentation or omission of facts called for is cause for dismissal at any time without any previous notice. I hereby give the Company permission to contact schools, previous employers (unless otherwise indicated), references, and others, and hereby release the Company from any liability because of such contract.

I understand that, in connection with the routine processing of your employment application, the Company may request from a consumer reporting agency an investigative consumer report including information as to my credit records, character, general reputation, personal characteristics, and mode of living. Upon written request from me, the Company will provide me with additional information concerning the nature and scope of any such report requested by it.

I further understand that my employment with the Company shall be probationary for a period of ninety (90) days, and further that at any time during the probationary period or thereafter, my employment relation with the Company is terminable at will for any reason by either party.
Full Name
Phone Number

Area CodePhone Number
Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
EQUAL EMPLOYMENT OPPORTUNITY QUESTIONAIRE
The following information we are soliciting is strictly voluntary. This form will be kept separate and confidential from the application.

Information provided on this form will not be considered in any employment decision but is for statistical purposes only.
Tilte of Position Applied for:
Date

MonthDayYear
Full Name

First NameLast Name
Age
Gender

MaleFemale
Race/Ethnic Origin (Select ONLY One)

White (not of Hispanic origin): Persons having origins in any of the original people of Europe, North Africa, or the Middle East.Black (not of Hispanic origin): Persons having origins in any of the black racial groups of Africa.Hispanic: Persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish cultures or origins regardless of race.Asian or Pacific Islander: Persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, or the Pacific Islands. This includes, for example, China, India, Japan, Korea, the Philippine Islands, and Samoa.American Indian or Alaskan Native: Persons having origins in any of the original people of North American and who maintain cultural identification through tribal affiliation or community recognition.
How did you learn about this position?

Employment OfficeCity EmployeeSchoolNewspaperInternetCareer FairWalk-InOther
Do you have any physical or mental disabilities which may limit your ability to perform essential functions of this job or which would require any special accommodations?

YesNo
If Yes, Please explain:
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Application for Employment

Education:

Position Desired

Employment History

Personal References

EQUAL EMPLOYMENT OPPORTUNITY QUESTIONAIRE