NIE Behavioral Health Job Application

NIE Behavioral Health Job Application

Complete this application carefully and include all required certifications, authorizations, and consent signatures.
Applicant Information
Last Name*
First Name*
Middle Name
Application Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
E-mail*
example@example.com
Candidate Resume*

PDF, DOC, or DOCX
Cancelof
YesNo
YesNo
Job Interest

Position & Availability
Position Desired*
Full-timePart-timeDaysWeekends
Available to Start*

MonthDayYear
Date
Expected Pay per Hour
Average Hours per Week Desired
How Did You Learn About Us?
YesNo
Education
College Name and Address
College Course of Study
College Years Completed
YesNo
College Degree/Certificate/Diploma
High School Name and Address
High School Years Completed
YesNo
High School Degree/Certificate/Diploma
Computer Skills
Professional References
Reference 1 Name*

First NameMiddle NameLast Name
Reference 1 Company Name*
Reference 1 Telephone*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 1 Title/Position*
Reference 1 How long have you worked together?*
Reference 2 Name*

First NameMiddle NameLast Name
Reference 2 Company Name*
Reference 2 Telephone*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 2 Title/Position*
Reference 2 How long have you worked together?*
Reference 3 Name*

First NameMiddle NameLast Name
Reference 3 Company Name*
Reference 3 Telephone*
Please enter a valid phone number.Format: (000) 000-0000.
Reference 3 Title/Position*
Reference 3 How long have you worked together?*
Employment History
Employer 1*
YesNo
Telephone 1
Please enter a valid phone number.Format: (000) 000-0000.
Address 1

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Dates of employment 1*
Supervisor/Manager Name 1
Supervisor/Manager Position 1
Job title 1
Job responsibilities 1
Reason for leaving 1
Employer 2*
YesNo
Telephone 2
Please enter a valid phone number.Format: (000) 000-0000.
Address 2

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Dates of employment 2*
Supervisor/Manager Name 2
Supervisor/Manager Position 2
Job title 2
Job responsibilities 2
Reason for leaving 2
Employer 3*
YesNo
Telephone 3
Please enter a valid phone number.Format: (000) 000-0000.
Address 3

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Dates of employment 3*
Supervisor/Manager Name 3
Supervisor/Manager Position 3
Job title 3
Job responsibilities 3
Reason for leaving 3
Applicant Certification
I certify that the information provided by me in this application and accompanying material is accurate and complete to the best of my knowledge. I understand that if I am employed by NIE HEALTH any misrepresentation or material omission made by me on this application, resume or accompanying material may result in cancellation of this application or immediate discharge from the COMPANY, whenever it is discovered. I hereby give NIE HEALTH the right to contact and obtain information from my references, employers, and educational institutions and to otherwise verify the accuracy of the information contained in this application. Further, I hereby release from liability NIE HEALTH and its representatives for seeking, gathering and using such information and all other persons, corporations or organizations for furnishing such information and I release all of my previous employers and all their employees, representatives, officers, directors and agents from any claims arising out of, or in any way connected with, the disclosure to NIE HEALTH of information from my personnel files or any other information pertaining to my employment. I understand that neither the acceptance of this application nor the subsequent entry into any type of employment relationship with NIE HEALTH creates an actual or implied contract of employment. If I am hired, I understand that my employment is at-will and that either NIE HEALTH or I may terminate my employment at any time for any lawful reason. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that, if I am hired by NIE HEALTH my offer of employment is subject to a satisfactory background screening, to include but is not limited to: reference checks, educational and work verification, a health assessment, and a CORI/criminal record. I have read, or have had read to me, this section and fully understand these conditions as outlined above.
Signature of Applicant*
Date*

MonthDayYear
Date
Should be Empty:

NIE Behavioral Health Job Application

Applicant Information

Job Interest

Education

Professional References

Employment History

Applicant Certification