General Information

Education and Training

High School or Equivalent

College/University

Additional Training/Professional School

License & Certification

List any professional licenses or certifications relevant to behavioral health care in the following format:

1. License Name: answer

Issuing Body: answer

License Number: answer

Expiration Date: answer

Employment History

List your last three employers from most recent to least in the following format:

1. Employer: name

   Address: address, city, state zip

Dates employed: mm/yyyy - mm/yyy

Supervisor and phone number: name-number

Key duties and achievements: list

Reason for leaving: answer

May we contact: answer yes/no

Behavioral Health/Addiction Care Experience

Skills and Qualifications

Availability

Background Information

*Conviction will not necessarily disqualify an applicant from employment; factors such as age and time of the offense, seriousness and nature of violation, and rehabilitation will be considered.

Applicant Statement & Signature

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any misrepresentation or omission of facts may result in rejection

of my application or, if employed, termination. I authorize the Company to verify any information contained in this application (except as noted) and to obtain reference information on my work performance. I release the Company and any persons or entities providing such information from any and all liability arising therefrom. I understand that employment with the Company is "at will", meaning that either I or the Company may terminate employment at any time, with or without cause or notice.

Equal Employment

This organization is an equal opportunity employer and does not discriminate on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, or any other legally protected status.