River City Behavioral Health LLC

Full Name (first and last)

Date

Please list any other names you have worked under or used in the past

Street number

AptUnit

City

State

Zip

Phone number

Email

example@example.com

Do you have a vehicle in good running condition?

YesNo

Do you have current CPR certification (that includes infants and children)?

YesNo

Are you able to perform the duties for the position you are applying for?

YesNo

Are you the parent, family member, or friend of a client currently receiving services?

YesNo

Have you ever been convicted of a felony?

YesNo

If yes, please explain:

Upon offer of employment, will you be able to provide verification of your legal rights to work in the United States?

YesNo

If no, please explain?

Education

Institution #1 name:

City and state:

Degree / Certification received:

Institution #2 name:

City and state:

Degree / Certification received:

Institution #3 name:

City and state:

Degree / Certification received:

POSITION APPLYING FOR / AVAILABILITY / WAGE

Desired Position: RBT / CBT | BCaBA /LaBA | BCBA / LBA | Admin Assistant |

Date available to start

Date

Desired number of hours per week (a range is adequate)

Please input hour availability Monday-Friday

Desired wage

Are you able to travel using your own vehicle?

Please list skills that you have that would make you successful in this Job?

Employment History

Current company name or most recent employer

Position Held

Address

Dates Employed (start)

Date

Dates Employed (end)

Date

Manager / Supervisor

Wage / Salary

Phone number

Reason For Leaving

Current company name or most recent employer

Position Held

Address

Dates Employed (start)

Date

Dates Employed (end)

Date

ManagerSupervisor

Wage / Salary

Phone number

Reason For Leaving

References (please do not incoude relatives)

Reference #1 (name):

Address

Occupation

Telephone

Years Known

Reference #2 (name):

Address

Occupation

Years Known

River City Behavioral Health, LLC. is an equal opportunity employer, dedicated to a policy of non-discrimination in employment on any basis including but not limited to: age, gender, sexual orientation, color, race, national origin, religious persuasion, marital status, political beliefs, and/or disability that does not prohibit performance of essential job functions. Federal law prohibits the employment of unauthorized aliens. All persons hired must submit satisfactory proof of employment authorization and identity (valid driver's license, birth certificate, alien registration card, etc within three (3) days of being hired. Failure to submit such proof within the required time shall result in immediate employment termination. This application is valid for ninety (90) days. If you have not heard from us and would still wish to be considered for employment, it will be necessary for you to fill out a new application.

This Application for Employment is used to notify me that the nature and scope of investigation, if one is conducted, could include such general identification information as residence verification and, as applicable, information concerning my employment, education, general reputation, character, personal characteristics and habits, and that such information may be developed through personal interviews with third parties such as family members, neighbors, friends, associates, former employers, financial sources, and custodians of official records. Only job-related information developed from such a report will be considered in evaluating my employment application or continued employment.

River City Behavioral Health, LLC I 7521 E. Nora Ave. Spokane Vly, WA 99212 | Business: (509) 475-1807 | Behavioral Health Agency Anthony Gassman, BCBA, LBA

By signing below, I am acknowledging the following: I hereby authorize any and all listed references, former schools, former and/or current employers, and their agents and employees to answer all questions or release any information regarding my employment or educational experiences with them, and I hereby release any and all listed references, former schools, former and/or current employers, and their agents and employees from any liability and hold them harmless from any claim for releasing any truthful information within their knowledge and/or records. I authorize River City Behavioral Health, LLC. to release to any person, firm, entity, or organizations with which I may seek employment, any truthful information concerning my work experience with River City Behavioral Health, LLC., and I hereby release River City Behavioral Health, LLC. and hold them harmless from any claim for releasing any truthful information within its knowledge and/or records. I understand and agree that, if hired, my employment is for no definite period and either I or River City Behavioral Health, LLC. may terminate our relationship at will at any time, without notice or any reason, and that this employment application does not constitute an employment contract, and I certify that all the above information that I provided is true to the best of my ability. I understand that if I were to be hired by RiverCity Behavioral Health, LLC. and had falsified any of my pre-employment records, it would result in termination of my employment.

Signature of Applicant

Date

River City Behavioral Health, LLC I 7521 E. Nora Ave. Spokane Vly, WA 99212 | Business: (509) 475-1807 | Behavioral Health Agency | Anthony Gassman, BCBA, LBA

River City Behavioral Health LLC

APPLICATION FOR EMPLOYMENT