Employment Application Form

Employment Application

Complete the form below accurately and entirely, and upload all supplemental documentation.
Personal Information
Name*

First NameLast Name
Birth Date

MonthDayYear
Social Security Number*
Phone Number*
Format: (000) 000-0000.
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Resume

If you upload a resume, you may skip the Employment History and References sections.
File Upload

Cancelof
Position & Availability
Position applying for:
Availability (check all that apply):

MorningAfternoonEveningWeekendsHolidays
Have you worked for QBHS before? (If yes, provide dates and reason for leaving below. If no, skip the next question.)

YesNo
Dates employed at QBHS and reason for leaving:
Work Eligibility
Are you legally authorized to work in the United States?

YesNo
Can you perform the essential functions of the position for which you are applying?

YesNo
Have you ever been convicted of a felony? (If yes, provide dates and details below. If no, skip the next question.)

YesNo
Felony conviction dates and details:
Employment History

Complete this section only if you have not submitted a resume.
Job #1
Job #2
Job #3
Education & Training
Highest level of education completed:
College/University/Technical School #1
College/University/Technical School #2
College/University/Technical School #3
Relevant Skills & Training
Select all that apply:

AccountingAdministrative/SecretarialCustomer RelationsCPRCrisis InterventionFirst AidGeneral OfficeComputer SkillsSocial WorkMental Health / MHS / MHPOther
List any additional skills not listed above:
Licenses & Credentials
Click "save" to enter multiple credentials.
References

Please list two (2) references who are familiar with your work history.
Reference #1
Reference #2
Military Service
How did you hear about us?*

College RelationJob/Community FairCommunity OutreachNewspaperDirect RecruitSearch FirmInternal CandidateInternetState Employment AgencyTemporary AgencyWalk‑In / Write‑InEmployee Referral (name)Other
Required Acknowledgements
Check each box to acknowledge the following:*

I certify that all information provided is true and complete.I understand that false or misleading information may result in termination.I authorize QBHS to contact employers, references, and verify information.I release all parties from liability regarding information provided.I understand employment is at‑will and may be terminated at any time.I agree to comply with QBHS rules and return company property upon termination.I understand a physical exam and drug screening may be required after a contingent offer.I understand this application is active for 180 days and I must reapply after that time if I am still interested in employment at QBHS.
Applicant Signature
Signature Signature Date Date
Should be Empty:

Employment Application

Personal Information

Resume

Position & Availability

Work Eligibility

Employment History

Education & Training

Relevant Skills & Training

Licenses & Credentials

Military Service

Required Acknowledgements

Applicant Signature