Bridgemont - Employment Application Form

Position Applied For

Earliest Possible Start Date

Date

Hourly Rate / Salary Desired

Name

First NameLast Name

E-mail

example@example.com

Phone Number

Format: (000) 000-0000.

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you eligible to work in the U.S.?

Are you at least 18 years or older? (If not, you may be required to provide authorization to work.)

Have you ever been convicted of a crime, including sexual related offenses?

A conviction will not necessarily automatically disqualify you from employment. Rather, such factors as age and date of conviction, seriousness and nature of the crime, and rehabilitation will be considered.

If yes, please provide details (i.e. dates and location for all convictions).

Have you ever been terminated from employment or asked to resign by an employer?

If yes, please provide company name(s) and details.

What shifts are you available to work?

Can you work overtime, including weekends?

Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodation(s)?

Are you currently employed?

If yes, may we inquire of your present employer?

How did you hear about us? (Choose all that apply.)

Have you ever worked for Bridgemont before?

If yes, please explain

Do you know anyone who works for Bridgemont?

If yes, who?

Education

Rows	Name and Location of School	# of yrs attended	Degree Received	Subjects Studied /Major	CurrentlyEnrolled
College or University
High School
Trade, Business, or Correspondence School Name

Do you have any current professional licenses?

State

License No.

Expiration Date

Date

Do you have any special skills, foreign languages, sign language, experience and/or training that would enhance your ability to perform the position applied for? If yes, Please explain:

Have you ever had any job related training in the United States military?

If yes, please describe.

From

To

Employer Name

Phone #

Job Title

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Immediate Supervisor and Title

Summarize the nature of work performed and job responsibilities.

Hourly Rate / Salary

Reason for Leaving

From

To

Employer Name

Phone #

Job Title

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Immediate Supervisor and Title

Summarize the nature of work performed and job responsibilities.

Hourly Rate / Salary

Reason for Leaving

From

To

Employer Name

Phone #

Job Title

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Immediate Supervisor and Title

Summarize the nature of work performed and job responsibilities.

Hourly Rate / Salary

Reason for Leaving

Give the names of three (3) previous supervisors or co-workers

Please read carefully before signing.

The Mental Health Center is an equal opportunity employer. The Mental Health Center does not discriminate in employment on account of race, color, religion, national origin, citizenship status, ancestry, age, sex, sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service.

I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for The Mental Health Center to hire me. I understand that no representative of The Mental Health Center has the authority to make any assurance to the contrary.

I attest with my signature below that I have given to The Mental Health Center true and complete information on this application. No requested information has been concealed. I authorize The Mental Health Center to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.

Date

Signature

APPLICATION FOR EMPLOYMENT

Personal Information

Employment Eligibility

Referral Source

Employment History

Professional References

THIS APPLICATION IS VALID FOR 60 DAYS FROM THE DATE SIGNED/DATED ABOVE.