Application for Employment

Psychiatric Medical Care
An Equal Opportunity Employer

We are an Equal Opportunity Employer. It is the Company's policy to not unlawfully discriminate against any applicant or employee on the basis of race, color, national origin, religion, sex, age, disability, sexual preference or identity, genetic information, military service, or any other category protected by federal, state or local laws. The Company also prohibits harassment of applicants and employees based upon these protected categories.

Job applications will be considered active until the position applied for has been filled. If you wish to be considered for employment after that, you must reapply. Please read and complete all sections carefully before signing. False, incomplete, or misleading information will result in rejection during the hiring process or termination of employment if subsequently discovered.

Personal Information

Name
Address
City
State
Zip Code
Number of years at present address
Previous Address
Previous City
Previous State
Previous Zip Code
Number of years at previous address
Home Phone Number
Cell Phone Number
Email Address
Are you at least 18 years of age?
Are you legally eligible for employment in the USA?

Employment Sought

Position Desired
Full time?
Date Available
Are you available to work overtime as needed?
If the position for which you are applying requires driving of any vehicle, do you have a current, valid, unrestricted driver's license?
(You must be qualified, licensed, and insurable in order to hold any position that requires driving.)
Who referred you to this position?
Have you read the job description of the position for which you are applying?
Can you, with or without a reasonable accommodation, perform the essential functions of the job for which you are applying, including any attendance requirements?
(If you have any questions about the functions of the job, please ask the interviewer before answering.)
Do you have adequate transportation to and from work?
SCHEDULING: Our facilities must be adequately staffed to maintain quality patient care. Work schedules are varied and require some flexibility.
Do you have any commitments to another employer which might affect your employment with us?
If yes, explain fully.

Employment Background

List your present or most recent employer first and include military service if among last four jobs. Give exact dates of employment if applicable. You may list volunteer experience if you do not have paid work experience with four employers (type "V" into the salary field).

Employer
Address
City
State
Zip Code
Phone
Employment
Start Date
Employment
End Date
Job Title
Supervisor
Primary
Job Duties
Final Salary
Reason
For Leaving

Employer
Address
City
State
Zip Code
Phone
Employment
Start Date
Employment
End Date
Job Title
Supervisor
Primary
Job Duties
Final Salary
Reason
For Leaving

Employer
Address
City
State
Zip Code
Phone
Employment
Start Date
Employment
End Date
Job Title
Supervisor
Primary
Job Duties
Final Salary
Reason
For Leaving

Employer
Address
City
State
Zip Code
Phone
Employment
Start Date
Employment
End Date
Job Title
Supervisor
Primary
Job Duties
Final Salary
Reason
For Leaving

All references may be checked, except for the following: (Leave blank if all references, including your present employer, can be checked.)
Explain any circumstances you wish to be considered in regard to any of the references listed above:
If your former employment, education or military services is under a name other than the one indicated on front of application, please list it here:

Professional References

List three persons, not former employers or relatives, whom you have known at least one year.

Reference Name
Occupation
Address
City
State
Zip Code
Phone
Years
Acquainted

Reference Name
Occupation
Address
City
State
Zip Code
Phone
Years
Acquainted

Reference Name
Occupation
Address
City
State
Zip Code
Phone
Years
Acquainted

Education

SchoolName of SchoolLast Year
Completed
Did you
Graduate?
Diploma
or Degree
Elementary/Middle
High School
College
Other (Specify)

Type License/
Registration
StateNumberExpiration Date

If you don't have the required license, have you applied?
Has your professional license ever been suspended or revoked?
If yes, please explain:

Criminal History

Successful applicants will be required to undergo a full criminal background check before placement. A prior criminal history does not constitute an automatic bar to employment. Factors such as age and time of the offense, seriousness and nature of the violation and rehabilitation will be taken into account.

Do you currently have any criminal charges, other than minor traffic offenses (DUI / DWI is NOT minor) that are pending against you or awaiting disposition? (DO NOT disclose any charge that has been dismissed or otherwise disposed of.)
If yes, please give dates and details:

Additional Information

Have you ever been employed by the Company?
From
To
Position
Supervisor

Please Read Carefully

I understand and acknowledge that this application does not create an offer of employment and that to the extent I receive an offer of employment, that offer is conditional upon my passing a pre-employment background check and a pre-placement medical examination / drug and alcohol screen.

The Company complies with the ADA, the ADAAA and applicable state law and considers reasonable accommodation measures that may be necessary for qualified applicants/employees to perform the essential functions of the job.

I understand that all employment with the Company is on an “at-will” basis and that either I or the Company have the right to terminate employment at any time for any reason not otherwise prohibited by law.

Except as noted otherwise above, by signing below, I authorize the Company to investigate my references and prior employment record, and I release the Company and all other parties from liability for any damage that may result from, or is related to, the furnishing of information related to my references or my prior employment record to the Company. I understand that, if I am hired, it is critical that I am at work when scheduled and therefore I am responsible to make the necessary transportation arrangements to ensure that I am at work on time and as scheduled.

I agree to conform to the employer’s substance and abuse policy and agree to submit to drug tests as required by the employer.

I understand that smoking is prohibited in all indoor areas unless designated smoking areas have been established by a particular Company in accordance with applicable state and local law.

By my signature below, I certify that all statements and answers in this application are true and correct and agree that any untrue or misleading answer, omission, concealment or failure to answer any question fully, completely and accurately will be grounds for terminating my employment with the Company, regardless of when discovered.