RPTC Application

Application for Employment

Renewed Purpose Treatment Center LLC
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?
Are you authorized to work and remain in the United States?
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.
If Yes, Explain:
Education:
Are you a High School Graduate?
High School Equivalency?
Are you presently attending school?
Type of Education
Name of Instiution
Field of Study
Type of Degree
Did you Graduate?
Do you have additional education to enter?
Additional Type of Education
Name of Instiution
Field of Study
Type of Degree
Did you Graduate?
Position Desired
Position(s) applied for
Desired Work Schedule
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?
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?
May we contact your former employers?
How you ever been employed with this company?

Other
Do you have any friends or relatives employed by this company?
If yes, please provide their names and relationship to you.
Personal References
Full Name

First NameLast Name
Business or Occupation
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Full Name

First NameLast Name
Business or Occupation
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Full Name

First NameLast Name
Business or Occupation
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
APPLICATION FORM WAIVER – PLEASE READ CAREFULLY

CERTIFICATION

I hereby certify that all entries on the application and any attachments are true and complete and I agree and understand that any falsification of information herein, regardless of time of discovery may cause forfeiture on my part to any employment with Renewed Purpose Treatment Center, I understand that all information on this application is subject to verification and I consent to reference and former employers and educational institutions listed being contacted regarding this application. Finally, I attest, under penalty of perjury, that I am legally authorized to work in the United States of America.
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
Race/Ethnic Origin (Select ONLY One)
How did you learn about this position?

Other
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?
If Yes, Please explain:
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Application for Employment

Education:

Position Desired

Employment History

Personal References

EQUAL EMPLOYMENT OPPORTUNITY QUESTIONAIRE