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Online Application - Focus Behavioral Health


 
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PLEASE DO NOT USE APOSTROPHES



Personal Information




*First Name

*Last Name

*MI

*Address

*City

*State

*Zip

*Phone Number

*Email Address



Position Information

              Position Applied For
Program Applied For
Available To Work
           
           
*Are There Any Days Or Hours You Are Unable To Work?

           If Yes, Specify 
           
Date Available To Start

Desired Salary

Least Acceptable Salary
           



Other Information

How Did You Hear About Focus Behavioral Health, Inc.? (ex. friend, co-worker, walk-in, etc.)

*Have You Ever Been Employed By Any Affiliate Or Division Of Focus Behavioral Health, Inc.?
          If Yes, Give Entity And Date(s) 

*Have You Ever Filed An Application With Any Affiliate Or Division Of Focus Behavioral Health, Inc.?
          If Yes, Give Entity And Date(s) 

*Are You Authorized To Work In The United States?

*If Your Are Under 18, You Will Be Required To Furnish A Work Permit Before You Begin Working.
          *Initials 



Work History

List The Names Of 3 Different Employers, Giving The Most Recent Position First. Please Give The Month And Year For Each Position Listed.
In Addition, Be Sure To List All Health Or Human Service Providers For Which You Have Worked.

Employer #1
Employer Name
Address
City
State
Zip
Phone
Job Title
Duties
Supervisor
Reason For Leaving

Dates Employed From (MO/YR)

To (MO/YR)

Salary Started

Salary End






Employer #2
Employer Name
Address
City
State
Zip
Phone
Job Title
Duties
Supervisor
Reason For Leaving

Dates Employed From (MO/YR)

To (MO/YR)

Salary Started

Salary End






Employer #3
Employer Name
Address
City
State
Zip
Phone
Job Title
Duties
Supervisor
Reason For Leaving

Dates Employed From (MO/YR)

To (MO/YR)

Salary Started

Salary End




Past Information

*Have You Ever Been Disciplined Or Discharged By An Employer For Client Abuse Or Negelect? ** (A "Yes" Answer Does Not Automatically Disqualify You For Employment.)**
          If Yes, Please Explain  

*Have You Ever Been Convicted Of (Or Plead Guilty To) A Felony, Including Driving While Intoxicated?
          If Yes, Please Explain  

**(Information Regarding Convictions Will Not Necessarily Disqualify You For Employment, But Will Be Reviewed In Light Of The Duties And Responsibilities Of The Position Being Sought)**



Driver's License Information

*A Valid Driver's License And Accetable Driving Record Are Required For Many Positions
*Driver's License State *Driver's License Number *Currently Valid?



Education

Graduate/Professional
Name
Address
City
State
Zip
Years Completed
Graduated?
Major
Degree



Undergraduate College
Name
Address
City
State
Zip
Years Completed
Graduated?
Major
Degree



*High School
*Name
Address
*City
*State
Zip
*Graduated?



Professional Licenses And/Or Certifications

List Any Professional Licenses & License Number(s)

Has Your Professional License Ever Been Suspended Or Revoked?
          If Yes, Please Explain  

List Any Certifications

*Have You Signed A Restrictive Covenant/Non-Compete Agreement Or Confidentiality Statement At A Prior Job?
          If Yes, Please Explain  



Military Experience

U.S. Military Service?
Branch

Date Entered

Date Discharged

Describe Any Job Related Training Received In U.S. Military



Related Information


Please List Any Other Qualifications, Professional Organizations, And/Or Volunteer Experiences That Are Applicable To The Position For Which You Are Appling. You May Exclude Any Whose Name Would Indicate The Race, Religion, Creed, Color, National Orgin, Or Ancestry Of Its Members.


If You Worked For Previous Employers Under Orther Names, Please Give Those Names



References

*Are You Currently Employed?

If Yes, May We Contact Your Present Employer?


I hereby give Focus Behavioral Health, Inc., and any of its staff, affiliates, and divisions, permission to contact my current employer. I release from all liability all persons, companies, and corporations supplying information. I indemnify Focus Behavioral Health, Inc., against any liability which might result from this contact.

*Initials 



Give Three Work-Related References

Reference #1

Employer Name
Address
City
State
Zip
Phone
Occupation




Reference #2

Employer Name
Address
City
State
Zip
Phone
Occupation




Reference #3

Employer Name
Address
City
State
Zip
Phone
Occupation



Resume

If You Have A Resume, Please Upload It Here.





Authorization And Release Of Information

I hereby give Focus Behavioral Health, Inc., and any of its affiliates and divisions, the right to thoroughlt investigate my past employment, education, police record, activities, and I release from all liability all persons, companies, and corporations supplying such information. I indemnify Focus Behavioral Health, Inc. against any liability which might result from conductiong such an investigation.  *Initials 

I understand that any false answers or statements or implications made by me in this application or other required documents shall be considered sufficient cause for denial of employment or discharge.  *Initials 

Additionally, I understand that nothing contained this employment application or in the granting of an interview is intended to create an employment contract between Focus Behavioral Health, Inc. and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me and I understand that no such promise or guarentee is binding upon Focus Behavioral Health, Inc. unless made in writing by the President.  *Initials 

If any employment relationship is established, I understand that I have the right to terminate my employment at any time for any reason or no reason at all, with or without prior notice, and that Focus Behavioral Healht, Inc. retains the same right.  *Initials 

You consent and agree that your use of a key pad, mouse or other device to select an item, button, icon, checkbox, to enter text, or to perform a similar act/action, constitutes your signature, acceptance and agreement as if actually signed by you in writing. You further acknowledge and agree that the taking of any such actions by you is the only evidence needed of your intent to sign any such agreement, acknowledgment, consent, terms, disclosures or conditions. You also agree that no certification authority or other third party verification is necessary to the validity of your electronic signature; and that the lack of such certification or third party verification will not in any way affect the enforceability of your signature or any resulting contract. Finally, you understand and agree that the last four digits of your social security number are used to verify your identity, if ever needed in the court of law.  *Initials 
*Signature (Please Type Name As It Would Appear On Your Signature)
*Last 4 Digits Of Your Social Security Number (Verifies Your Identity)