Apply for an Employment Opportunity Fill out the application below and we'll be in touch! "*" indicates required fields Step 1 of 5 20% Personal InformationName* First Middle Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work Phone*Cell Number*Best Time To Contact You Email Address* Social Security Number (Voluntary): For Current Woodland Center Employees - Department Where You Work Are you legally eligible for employment in this country?* Yes No (If yes, verification will be required.)Are you 18 years of age or older?* Yes No Position applying for:* Date available to work?* What is your minimum salary requirement?* Were you referred by someone? If so, please list their name: Employment Conditions: Check as many as you are willing to work.* Regular, full-time Regular, part-time Temporary, full-time Temporary, part-time Can you travel if the job requires it?* Yes No Are you currently on "lay off" status and subject to recall?* Yes No EducationHigh School*Name and Address of InstitutionCourse of Study Major/MinorCircle Last Year CompletedDid you Graduate?Diploma / Degree Add RemoveCollege*Name and Address of InstitutionCourse of Study Major/MinorCircle Last Year CompletedDid you Graduate?Diploma / Degree Add RemoveOther (Specify)Name and Address of InstitutionCourse of Study Major/MinorCircle Last Year CompletedDid you Graduate?Diploma / Degree Add RemoveOther (Specify)Name and Address of InstitutionCourse of Study Major/MinorCircle Last Year CompletedDid you Graduate?Diploma / Degree Add RemoveWork Related Licensure (Check appropriate)* LICSW LP MD RN LMFT LPN None Licensed Professionals: Have you ever been reprimanded, censured, or otherwise disciplined by, or have you been subject to a corrective action/plan by an licencing board, peer review organization, third party payer, clinic, hospital, medial staff, or any health-related agency or organization? Yes No If yes, explain: Employment ExperienceList present and past employers beginning with your most recent positionDate Employed From/To* Employer* Job Title* Employer Phone Number* Employer Address*May we contact this employer?*YesNoIf no, please explain:* Full-Time Part-Time Other Summarize the nature of work performed and job responsibilities:*Reason for Leaving*Employer 2Date Employed From/To* Employer* Job Title* Employer Phone Number* Employer Address*May we contact this employer?*YesNoIf no, please explain:* Full-Time Part-Time Other Summarize the nature of work performed and job responsibilities:*Reason for Leaving*Employer 3Date Employed From/To Employer Job Title Employer Phone Number Employer AddressMay we contact this employer?YesNoIf no, please explain: Full-Time Part-Time Other Summarize the nature of work performed and job responsibilities:Reason for Leaving ReferencesList people who know you well, preferably from a work environment. Do not refer to an acquaintance or relative.*NameRelationship/TitleAddressCellphone or email address Add RemoveReferences #2*NameRelationship/TitleAddressCellphone or email address Add RemoveReferences #3NameRelationship/TitleAddressCellphone or email address Add Remove Signature of ApplicantIt is understood and agreed upon that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the employer's service if I have been employed. I give the employer the right to investigate all references and to secure additional information about me, if job-related. I hereby release from liability the employer and its representatives from seeking such information and all other persons, corporations or organizations for furnishing such information. The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant's consideration for employment on a basis prohibited by local, state or federal law. This application is current for 3 months. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application. I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary. I understand it is this county's policy not to refuse to hire a qualified individual with a disability because of this person's need for an accommodation that would be required by the ADA.Your SignatureDate* MM slash DD slash YYYY
