Job Application Select the jobs you would like to apply for: NonePart Time LPN/RNPart Time CookOutpatient CounselorPEER Support SpecialistBehavioral Health Assistant (Direct Care)Licensed CounselorFields marked with an asterisk (*) must be filled out before submitting.WE REQUIRE PRE-EMPLOYMENT DRUG SCREEN: Before you fill out this application for employment, please read this statement: Before any position is offered, an employee background check must be obtained. You will be asked to complete the Missouri Family Care Safety Registry Worker Registration form and provide a copy of your Social Security Card. All information will be kept confidential. * By checking, I acknowledge that I have read and understand the above statement regarding drug-screening requirements. Convictions related to any sexual assault, aggravated assault, all drug related offenses, murder, theft, battery, or any other crime involving personal injury; injury to a child, elderly individuals, disabled individual, or threat to another person; abandoning or endangering a child; trafficking in children; forgery; financial exploitation of the elderly and disabled; identity theft; aiding escape of a prisoner; supporting terrorism; and aiding suicide make you ineligible for employment. Background checks on all prospective employees are conducted by this agency. For insurance purposes, driving records will be checked on all employees required to drive a vehicle as stated in thier job description. If an employee is determined to be uninsurable, employment may be dismissed. Falsification of the application for employment and/or submitted resume is grounds for dismissal. * By checking, I acknowledge that I have read and I understand the statement above and give my authorization to obtain a background screening. PERSONAL DETAILSFirst Name *Middle NameLast Name *Social Security Number *Email Address *Contact DetailsAddress * City *Zip code *Telephone *Cell phoneHave you ever applied for employment with us before? * Yes NoIf yes: Month and YearPay Expected *Will you work overtime if asked? * Yes NoWhen are you available to begin work? *Are you legally eligible or employment in the United States? * Yes NoEDUCATIONGraduate SchoolName and Location of SchoolCourse of StudyNo. of Years CompletedDid you Graduate? Yes NoDegree or DiplomaCollegeName and Location of SchoolCourse of StudyNo. of Years CompletedDid you graduate? Yes NoDegree or DiplomaBusiness/Trade/TechnicalName and Location of SchoolCourse of StudyNo. of Years CompletedDid you graduate? Yes NoDegree or DiplomaHigh SchoolName and Location of SchoolCourse of StudyNo. of Years CompletedDid you graduate? Yes NoDegree or DiplomaMembership in Professional or Civic OrganizationsEMPLOYMENT HISTORYCompany Name (current or most recent)TelephoneAddressName of SupervisorJob TitleDescribe your work Employed from/to (month and year)Starting payEnding payReason for leaving Employed from/to (month and yar)Company Name #2TelephoneAddressName of supervisorJob TitleDescribe your work Starting payEnding payReason for leaving Company Name #3TelephoneAddressName of SupervisorJob TitleDescribe your work Employed from/to (month and yar)Starting payEnding payReason for leaving Company Name #4TelephoneAddressName of SupervisorJob TitleDescribe your work Employed from/to (month and yar)Starting payEnding payReason for leavingDo Not Contact-We may contact the employers listed above unless you indicate those you do not want us to contact.Employer NameReasonMILITARYDid you serve in the U.S. Armed Forces? Yes NoIf yes, what branch?Describe any training received relevant to the position for which you are applying Have you ever been bonded? Yes No If Yes, with what employers?Are you a US citizen? * Yes NoHave you been convicted of a crime in the past ten years, excluding misdemeanors and summary offenses, which have not been annulled, expunged or sealed by court? * Yes NoIf Yes, describe in full State names of relatives and friends working for us, other than your spouse * * The information provided in this Application for Employment is true, correct, and complete. If you employ me, any misstatement or omission of fact on this application may result in my dismissal. * By checking this box, I understand that acceptance of an offer of employment creates no obligation upon you, the employer, to continue to employ me in the future.Resume/CV Letters of Reference Are you 18 years of age or older? Yes No
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