Employment Application
Personal Information
Name
*
First Name
Last Name
Gender Identity
*
Please Select
Male
Female
Other
Date Of Birth
*
-
Month
-
Day
Year
Date
Race
*
Please Select
Hispanic or Latino
African American
Caucasian
Native American
Asian
Other Race
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Email
*
example@example.com
Which organization
Please Select
The Hope Shot
Alliance for Healthy Communities
What position are you applying for?
*
Please Select
Recovery Coach
All Ways Center
Coordinator
Executive Director
Navigator
Outreach Specialist
AHC Board Member
THS Board Member
Social Security Number
*
Tell us why you are interested in this position and how your background, skills, and experience make you a suitable candidate.
*
Employment Eligibility
Are you legally eligible to work in the U.S?
*
Yes
No
Have you ever been convicted of a felony? (This does not exclude you)
*
Yes
No
Please explain:
*
Are you a person with lived experience?
*
Yes
No
Recovery Date
*
-
Month
-
Day
Year
Date
Short description of Recovery Story
*
Employment History
Employer 1
*
Job Title
*
Dates of employment
*
Employer 2
Job Title
Dates of employment
Education
High School Education?
*
Please Select
Diploma
GED
None
College Education?
*
Yes
No
Degree?
*
Certifications
Do you have any certifications?
*
Yes
No
Certification 1
Date Obtained
/
Month
/
Day
Year
Date
Certification 2
Date Obtained
/
Month
/
Day
Year
Date
Certification 3
Date Obtained
/
Month
/
Day
Year
Date
Write 3 words that describe your strengths and why
Strength 1
*
Why?
*
Strength 2
*
Why?
*
Strength 3
*
Why?
*
Write 1 word that describes a weakness and why
Weakness
*
Why?
*
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Disclaimer
Applicant understands that this is an Equal Opportunity Employer and committed to excellence through diversity. In order to ensure this application is acceptable, please print or type with the application being fully completed in order for it to be considered. Please complete each section EVEN IF you decide to attach a resume. I, the Applicant, certify that my answers are true and honest to the best of my knowledge. If this application leads to my eventual employment, I understand that any false or misleading information in my application or interview may result in my employment being terminated.
*
Print Name
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
Date
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