EMPLOYMENT APPLICATION WITH LIVED EXPERIENCE ATTESTATION
Position Applied For: Peer Support Specialist
Date of Application:
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SECTION A: PERSONAL INFORMATION
Legal Name
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First Name
Last Name
Preferred Name:
Address:
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City, State, ZIP:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary Phone:
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Secondary Phone:
Email
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example@example.com
Are you legally eligible to work in the United States?
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Yes
No
Do you have a valid Arizona Driver's License?
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Yes
No
If hired, when could you start?
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SECTION B: LIVED EXPERIENCE ATTESTATION
Important: The Arizona Department of Gaming requires that Peer Support Specialists have personal lived experience with problem gambling and sustained recovery. This information is collected for qualification purposes only and will be handled with the utmost confidentiality.
1. Lived Experience with Problem Gambling
I self-identify as an individual who has personal lived experience with problem gambling disorder.
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Yes - I have personal lived experience with problem gambling disorder.
No - I do not have this lived experience.
2. Duration of Lived Experience
My lived experience with problem gambling spans:
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Less than 1 year
1-2 years
2+ years
5+ years
10+ years
3. Sustained Recovery
I have experienced sustained recovery from problem gambling for:
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Less than 6 months
6-12 months
1-2 years
2+ years
5+ years
10+ years
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4. Recovery Philosophy Statement
Please briefly describe your recovery journey and philosophy (2-3 sentences):
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5. Willingness to Share Experience
As a Peer Support Specialist, you will ethically use your lived experience to support others. Are you comfortable with this aspect of the role?
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Yes, I am comfortable and prepared to use my experience to help others.
I have some concerns I would like to discuss.
No, I would prefer not to share my personal experience.
Attestation Statement:
I certify that the information provided in this section is true and accurate to the best of my knowledge. I understand that misrepresentation may disqualify me from employment or result in termination if discovered after hiring.
Type a question
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Date:
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SECTION C: EMPLOYMENT & EDUCATION HISTORY
Name of Most Recent Employer:
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Position:
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Dates:
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To
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Responsibilities:
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Previous Employer:
Position:
Dates:
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To
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Responsibilities:
Education: (Highest level completed)
Highest level completed
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High School/GED
Some College
Associate's Degree
Bachelor's Degree
Graduate Degree
None
Field of Study:
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Certifications/Training: (Include any relevant training, even if not completed)
Certifications/Training
Arizona Peer Recovery Support Specialist Certification
Problem Gambling Specific Training
CPR/First Aid
Other
Expiration Date
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SECTION D: PEER SUPPORT SPECIFIC QUESTIONS
1. Why do you want to be a Peer Support Specialist for problem gambling?
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2. What do you believe are the most important qualities of an effective Peer Support Specialist?
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Are you fluent in more than one language?
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Yes
No
What languages are you fluent in?
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SECTION E: REFERENCES
Note: References from individuals familiar with your recovery journey are acceptable and encouraged.
Professional/Character Reference 1:
Name:
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Relationship:
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Phone:
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Email:
example@example.com
Organization:
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Professional/Character Reference 2:
Name:
Relationship:
Phone:
Email:
example@example.com
Organization:
Personal/Character Reference 1:
Name:
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Relationship:
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Years Known:
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Phone:
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Email:
example@example.com
Personal/Character Reference 2:
Name:
Relationship:
Years Known:
Phone:
Email:
example@example.com
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SECTION F: BACKGROUND CHECK AUTHORIZATION
Arizona Fingerprint Clearance Card:
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I currently have a valid Arizona Fingerprint Clearance Card
I do not have a valid Arizona Fingerprint Clearance Card
I am not eligible for an Arizona Fingerprint Clearance Card
Exp.:
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Background Check Authorization:
I authorize Dezerve Counseling to conduct a background check, which may include criminal history, reference checks, and verification of the information contained in this application. I understand that employment is contingent upon satisfactory results.
Signature:
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Printed Name:
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Date:
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SECTION G: EQUAL OPPORTUNITY INFORMATION (Voluntary)
This information is for statistical purposes only and will not be used in hiring decisions.
Gender:
Male
Female
Non-Binary
Prefer not to say
Race/Ethnicity:
White
Black/African American
Hispanic/Latino
Asian
Native American/American Indian
Pacific Islander
Multi-Racial
Prefer not to say
Veteran Status:
Yes
No
Prefer not to say
Disability Status:
Yes
No
Prefer not to say
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