Job Applicant Information Form
Personal Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
*
Home Phone Number
Email Address
*
example@example.com
Which position are you applying for?
Please Select
Executive/Management
Counselor
Nurse Practitioner
Nurse
Medical Assistant
Practicum / Internship
Reception
Maintenance
Janitorial
Support Staff
Other
Please list the times you are available to work for each day, Monday through Friday.
*
Rows
Times between 8am and 7pm
Monday
Tuesday
Wednesday
Thursday
Friday
If needed, are you available for overtime?
Yes
No
Please list your current salary/hourly wage.
Please list your desired salary/hourly wage.
Have you ever applied for a job at the Counseling & Wellness Center in the past?
Yes
No
Will you submit to a substance screening?
Yes
No
Select your highest level of degree earned
Please Select
High School Diploma / GED
Associate's Degree
Bachelor's Degree
Master's Degree
PHD
Previous Employment
*
Rows
Name
Dates of Employment
Job Title
Supervisor Name
Rate of Pay
Most Recent Employer
Previous Employer
Previous Employer
References
*
Rows
Name
Relationship to Reference
Email Address
Reference 1
Reference 2
Reference 3
Please upload your resume/vitae
*
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