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*

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.?*

YesNo

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

YesNo

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

YesNo

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?*

YesNo

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

What shifts are you available to work?*

Full TimePart Time

Can you work overtime, including weekends?*

YesNo

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

YesNo

Are you currently employed?*

YesNo

If yes, may we inquire of your present employer?

YesNo

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

Have you ever worked for Bridgemont before?*

YesNo

If yes, please explain

Do you know anyone who works for Bridgemont?*

YesNo

If yes, who?

Education*

	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?*

YesNo

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?*

YesNo

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*

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.