Your Information


Position Information


Other Information


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 #2

Employer #3


Driver's License Information

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


Education

Graduate/Professional

Undergraduate College

High School


Professional Licenses And/Or Certifications



Military Experience


Related Information


References

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.


References

Give Three Work-Related References

Reference #1

Reference #2

Reference #3


Resume


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.

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.

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.

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.

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.