PHOENIX COUNSELING CENTER JOB APPLICATION

Phoenix Counseling Center
2505 Gaston Memorial Drive
Gastonia, NC 28054

Telephone: 704.718.8362 FAX: 704.397.5356

PCC is an Equal Opportunity Employer We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation, or any other legally protected status.

Name*

First NameMiddle NameLast Name

Email*

example@example.com

Address*

Address

Street Address Line 2

CityState

Zip Code

Date of Birth Used for Background Checks Only*

Date

Phone Number*

Social Security Number (Last 4 digits)*

Last 4 digits of SSN

Positions Applied For:*

Gastonia OfficeShelby OfficeLincolnton OfficeAny Location

Immigration Reform & Control Act

After employment, you will be required to submit verification of your legal right to work in the United States. Phoenix Counseling Center employs only United States citizens or aliens who can provide proof of identity and work authorization within 3 working days of employment. Phoenix Counseling Center participates in E-Verify.

If you are less than 18 years of age, can you provide required proof of your eligibility to work. to include work permit*

YesNo

Have you ever filed an application with us before?*

YesNo

Have you ever been employed with us before?*

YesNo

Are you currently employed?*

YesNo

May we contact your present employer?*

YesNo

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Proof of citizenship or immigration status will be required upon employment.*

YesNo

Are you available to work:*

FullTimePartTimeTemporary

Can you travel if a job requires it?*

Do you have a valid driver's license?*

YesNo

Do you have reliable transportation?*

YesNo

Do you have automobile insurance?*

YesNo

Have you been charged with and/or convicted of a felony?*

YesNo

Have you been charged or released from employment due to workplace aggression/violence?*

YesNo

Please list any Clinical Licensure Information or Certifications

Educational/Vocational Achievement

Name of High School (included GED equivalency)*

School Address (City & State)*

Dates Attended*

Month/Year Started

Dates Attended*

Month/Year Ended

Type of Degree or Diploma Received (N/A if not graduated)*

Name of College or University Attended*

School Address (City & State)*

Dates Attended*

Month/Year Started

Dates Attended*

Month/Year Ended

Type of Degree or Diploma Received (N/A if not graduated)*

Major Subjects Studied*

Technical, Vocațional or Military Training*

School Address (City & State)*

Dates Attended*

Month/Year Started

Dates Attended*

Month/Year Ended

Type of Degree or Diploma Received (N/A if not graduated)*

Major Subjects Studied*

Describe job related skills knowledge special training or licenses you have pertaining to the position Please identify skills using computer software such as Word Excel PowerPoint Access or other specialized computer software*

Indicate any foreign languages that you can speak read and/or write*

Describe any specialized training or experience that you feel relevant to the position you are applying for:*

List professional, trade, business or civic activities and offices held.*

Specialized Skills*

Are you capable of performing in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied?*

YesNo

I certify that the answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless an authorized executive of this organization specifically acknowledges such change in writing.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

Signature of Applicant(type your name)*

Type your name to indicate signature

Date*

Date

List two past supervisors and one person who is not related to you who would have knowledge of your qualifications for the position for which you are applying.

Reference 1 Name

Reference 1 Title/Relationship

Reference 1 Address(Street, City, State Zip)

Reference 1 Phone Number(include area code)

Reference 1 Occupation

Reference 2 Name

Reference 2 Title/Relationship

Reference 2 Address(Street, City, State Zip)

Reference 2 Phone Number(include area code)

Reference 2 Occupation

Reference 3 Name

Reference 3 Title/Relationship

Reference 3 Address(Street, City, State Zip)

Reference 3 Phone Number(include area code)

Reference 3 Occupation

Dates Available*

Date

Referral Source

Resume Upload

PCC Application for Employment

Reasonable Accommodations:

Applicant's Statement

Professional/Work References