Your Information First Name MI Last Name Address City State Zip Phone Number Email Address Position Information Position Applied For Program Applied For AAIDD Available To Work Full TimePart TimeTemporary Are There Any Days Or Hours You Are Unable To Work? YesNo If Yes, Specify Date Available To Start Desired Salary Least Acceptable Salary Other Information How Did You Hear About Focus Behavioral Health, Inc.? (i.e. friend, co-worker, walk-in, etc.) Have You Ever Been Employed By Any Affiliate Or Division Of Focus Behavioral Health, Inc.? YesNo 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. YesNo 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) Dates Employed to 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) Dates Employed to Salary Started Salary End Employer #3 Employer Name Address City State Zip Job Title Duties Supervisor Reason for leaving Dates Employed from (MO/YR) Dates Employed to Salary Started Salary End 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? YesNo Education Graduate/Professional Name Address City State Zip Years Completed 1234 Graduated? YesNo Major Degree Undergraduate College Name Address City State Zip Years Completed 1234 Graduated? YesNo Major Degree High School Name Address City State Zip Graduated? YesNo Professional Licenses And/Or Certifications List Any Professional Licenses & License Number(s) Has Your Professional License Ever Been Suspended Or Revoked? YesNo If Yes, Please Explain List Any Certifications Have You Signed A Restrictive Covenant/Non-Compete Agreement Or Confidentiality Statement At A Prior Job? YesNo If Yes, Please Explain Military Experience U.S. Military Service? YesNo 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 Other Names, Please Give Those Names References Are You Currently Employed? YesNo If Yes, May We Contact Your Present Employer? YesNo 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 References Give Three Work-Related References Reference #1 Address City State Zip Employer Phone Employer Occupation Reference #2 Employer Name Address City State Zip Employer Phone Employer Occupation Reference #3 Employer Name Address City State Zip Employer Phone Employer 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) Please leave this field empty.