An Equal Employment Opportunity Employer
We do not discriminate on the basis of race, color, national origin, sex, gender, marital status, disability, age, religion, veteran status or any other reason
Full Name
First Name
Last Name
Have you ever used another name?
Yes
No
Date of Application
-
Month
-
Day
Year
Date
Present Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you 18 years of age?
Yes
No
If yes, can you, if hired, submit a work permit?
Yes
No
Position Desired
Salary Desired
Is any additional information relative to a change of name, use of an assumed name, or a nickname necessary to enable a check on your work or education record?
Yes (If yes, please explain)
No
Are you available to work on weekends?
Yes
No
Would you be available to work overtime, if necessary?
Yes
No
If hired, would you have a reliable means of transportation to and from work?
Yes
No
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?
Yes
No
If no, describe the functions that cannot be performed:
Do you have any friends/relatives in our employment, if yes, Who:
Name/Relationship
Date you can start employment?
-
Month
-
Day
Year
Date
Have you ever applied or worked for this company before?
Yes
No
When?
Where?
Can you, after hire, submit verification of your eligibility to work in the United States?
Yes
No
Are you employed now?
Yes
No
If yes, may we inquire of your previous employer?
Yes
No
Have you even been convicted of a criminal offense (felony or serious misdemeanor?) *NOTE: a conviction will not necessarily disqualify an applicant for employment. Each instance will be considered in relation to the position for which you are applying.
Yes
No
If yes, state nature of the crime(s), when and where convicted and disposition of the case(s). Convictions for marijuana-related offenses that are more than two years old need not be listed.
Rows
Name & Location of School
Couse of Study
# of Years Completed
Did you Graduate?
Degree of Diploma
Graduate
College
Business/Trade/Technical
High School
Do you have any other experience, training, qualifications or skills which you feel make you especially suited for this position? If so, please explain
Have you obtained any special skills or abilities as the result of service in the military?
Yes
No
If so, please describe:
List below all present and past employment starting with your most recent employer (last 10 years is sufficient). Account for all periods of unemployment. You must complete this section even if attaching a resume.
Rows
Name, Address, & Phone # of Employer/Company
Supervisor's Name/Position
Last Position
Reason For Leaving
Date of Employment FROM TO
Job #1
Job #2
Job #3
Job #4
References
List below three persons not related to you who have knowledge of your work performance within the last three years.
Rows
Name of Reference
Occupation
Address (Street #-P.O Box)
Phone Number
Reference #1
Reference #2
Reference #3
We would like for you to review our mission statement and understand the importance of Alpha’s work in the community.
Mission Statement:
Alpha Behavioral Counseling Center offers professional and personable counseling services. We meet you where you are, offer an understanding and compassionate therapist to assess the nature of the problem, and work with you to reach your goals whatever they may be.
Please Read Carefully, Check Each Paragraph and Sign Below
*
I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.
I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.
I understand and agree that employment is “At-Will”, meaning employment may be terminated by either myself or the Company at any time, with or without cause, and with or without notice. I also understand and agree that the Company retains the right to demote, transfer, change my job duties, and my compensation at any time with or without notice and with or without cause in its sole discretion. Employer and Employee further understand and agree that other than the President, no manager, supervisor or other representative of the Company has authority to make any agreement, express or implied, for employment for any specified period of time, or to make any agreement for employment other than at-will. The Company and I also agree that this “At-Will” employment policy cannot be amended, modified or altered in any way by oral statements or in any other way, and can only be altered by written amendment signed by the President of the Company, indicating that it is intended as a modification of Employee’s At-Will status.
Date
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Month
-
Day
Year
Date
Signature of Applicant
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