Employment Application | Restoration Behavioral Health Systems

Non-Discrimination Policy: Restoration Behavioral Health Systems (RBHS) is committed to the principle of equal opportunity in education and employment. RBHS does not discriminate on the basis of sex, race, color, creed, national origin, age, religion, sexual orientation, gender identity, gender expression, veteran status, or disability in admission to, access to, treatment in, or employment in its programs and activities.
GENERAL INFORMATION
Date
MM slash DD slash YYYY
Position(s) Applied For
Name*
First Last
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Email
Cell Phone
Are you currently employed?
- Yes
- No
May we contact your employer?
- Yes
- No
Employment desired
- Full-Time
- Part-Time
- Shift Work
- Temporary
- Overtime
When are you available for work?
MM slash DD slash YYYY
Can you travel if a job requires it?
- Yes
- No

PROFESSIONAL LICENSE

(Only for positions which require professional license or certification)
Do you have a current license?
- Yes
- No
Professional license number
State of Issue
Expiration date
MM slash DD slash YYYY

OTHER SPECIAL SKILLS

Please list other special skills you may have, e.g., fluency in other languages, licenses, special training required for the position for which you are applying, etc.

WORK EXPERIENCE

Please list your work experience beginning with your most recent job. If you were self-employed, give firm name. Attach additional sheets if necessary. Exclude organization names which indicate race, color, creed, national origin, age, religion, sexual orientation, gender identity, gender expression, veteran status, or disability.
Most Recent Employer
Date Employed From
MM slash DD slash YYYY
Date Employed To
MM slash DD slash YYYY
Address
Supervisor
Job Title
Reason for Leaving
Work Performed
Need to add more work experience?*
- Yes
- No
Employer
Date Employed From
MM slash DD slash YYYY
Date Employed To
MM slash DD slash YYYY
Address
Supervisor
Job Title
Reason for Leaving
Work Performed
Add more work experience?*
- Yes
- No
Employer
Date Employed From
MM slash DD slash YYYY
Date Employed To
MM slash DD slash YYYY
Address
Supervisor
Job Title
Reason for Leaving
Work Performed
Any more work experience?*
- Yes
- No
Employer
Date Employed From
MM slash DD slash YYYY
Date Employed To
MM slash DD slash YYYY
Address
Supervisor
Job Title
Reason for Leaving
Work Performed

REFERENCES

Please list two references other than relatives or previous employers.
Name
Name
Position
Position
Company
Company
Address
Address
Phone
Phone

WAIVERS AND DISCLOSURES

Please read each section carefully and sign where indicated

AT-WILL EMPLOYMENT

It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this organization. I understand and agree that, if hired; my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or my employer. I also understand that this written statement supersedes any and all oral representations made by agents or representatives of this organization.

CERTIFICATION OF TRUTH AND ACCURACY

I certify that the information in this application is true, complete and correct. I understand that false answers, statements, or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge.
*
I have read and understand the above disclosures. I also understand that my typed named represents my signature for this application