Programs, services and employment are equally available to everyone. Please inform the Human Resources Department if you require reasonable accommodation for the application or interview.
Date of Interview (Month/Day/Year):
Applicant Data
Position Applied for: -Select Position - Clinical Counselor CCFA Clinician Wraps Clinician
How were you referred to us:
FULL NAME:
ADDRESS: CITY: STATE: ZIP CODE:
PHONE: MOBILE/PAGER/OTHER: EMAIL:
DATE AVAILABLE TO START: SALARY REQUIREMENTS:
SOCIAL SECURITY NO.
If you are under 18 years of age, can you provide a work permit? Yes No (If no, explain)
Are you a citizen of the United States? Yes No
If not, are you legally allowed to work in the United States? Yes No
Type of employment desired: Full –Time Part –Time Temporary Seasonal
Have you ever pleaded guilty, no contest or been convicted of a crime? Yes No
( If yes, give dates and details):
Answering yes to these questions does not constitute an automatic rejection for employment. Date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be considered.
Driver’s License Number (if applicable to position): State:
Summarize Your Special Skills or Qualifications
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Previous Employment (begin with most recent position)
Dates of Employment: From To:
Position(s) Held:
Company Name: Address:
City: State: Zip Code:
Phone: Supervisor: Title
Responsibilities:
Starting Salary and Title:
Ending Salary and Title:
Reason for Leaving:
May we contact this employer for a reference? Yes No
