Application for Employment

Woodward Academy

Application for Employment Form

Position Applying For: *

Street Address: *

Social Security Number: *

Primary Phone: *

Are you 21 years of age or older? *

Name (Last, First, Middle): *

City, State & Zip: *

Email Address: *

Alternative Phone: *

Have you ever been convicted of, pled guilty, had prosecution deferred, or plead no contest, to a felony or misdemeanor? Include convictions of DUI/DWI and driving with a suspended license. (A conviction will not necessarily disqualify you from the job for which you are applying) You are not required to disclose any erased, expunged, or pardoned convictions. *

If yes, when: *

Where: *

Please explain circumstances: *

Have you ever been employed by Vivant Behavioral Healthcare? *

If YES, give Dates: From: *

To: *

Department: *

Do you have anyone related to you now in the employment of Vivant Behavioral Healthcare? *

If YES, give Name(s): *

Department(s): *

MILITARY SERVICE

Have you ever served in any branch of the United States military and/or reserves? (copy) *

If YES, Branch of Service: *

Period of Active Duty: *

Highest Rank Held: *

Did you receive either a “bad conduct discharge” or “dishonorable discharge” from the military? Such a discharge will not necessarily disqualify you from the job for which you have applied. *

If YES, please explain circumstances: *

EDUCATION

High School: *

City/State *

Degree Type *

Did you graduate? *

Major *

If No, # of years left to graduate *

If Yes, date of Graduation *

GED School: *

City/State *

Degree Type *

Did you graduate? *

Major *

If No, # of years left to graduate *

If Yes, date of Graduation *

Undergraduate School: *

City/State *

Degree Type *

Did you graduate? *

Major *

If No, # of years left to graduate *

If Yes, date of Graduation *

Graduate/Professional School: *

City/State *

Degree Type *

Did you graduate? *

Major *

If No, # of years left to graduate *

If Yes, date of Graduation *

Other: *

City/State *

Degree Type *

Did you graduate? *

Major *

If No, # of years left to graduate *

If Yes, date of Graduation *

Certification/Licensure *

Please list all Professional Organizations and Associations: *

Please list all Professional Certification and Licensure (organization, type, expiration): *

HAVE YOU BEEN SUBJECT OF ANY ADVERSE ACTION(S) BY ANY DULY AUTHORIZED SANCTIONING OR DISCIPLINARY AGENCY FOR EITHER CONDUCT BASED OR PERFORMANCE BASED ACTIONS?IF YES, PLEASE EXPLAIN. *

SKILLS/EXPERIENCEPlease list technical skills, clerical skills, trade skills, etc., relevant to this position. Include relevant computer systems and software packages of which you have a working knowledge, and note your level of proficiency (basic, intermediate, expert) *

WORK HISTORYPlease list at least two previous employers even if you have provided a resume. The information provided by you in this section will be used to qualify you for employment. Failure to do so will limit your ability for employment.

1. Most recent employer: *

Employment From: *

Employed To: *

Employment Status *

Job Title *

Starting Salary: *

Ending Salary: *

Name and Address of Company: *

Supervisor’s Name, Title and Phone #: *

Other Name(s) Used: *

May we contact this employer for a reference? *

Job Duties and Responsibilities: *

Reason for Leaving: *

Employed From: *

Employed To: *

Employment Status: *

Job Title: *

Starting Salary: *

Ending Salary: *

Name and Address of Company: *

Supervisor’s Name, Title and Phone #: *

Other Name(s) Used: *

May we contact this employer for a reference? *

Job Duties and Responsibilities: *

Reason for Leaving: *

Employed From: *

Employed To: *

Employment Status: *

Job Title: *

Starting Salary: *

Ending Salary: *

Name and Address of Company: *

Supervisor’s Name, Title and Phone #: *

Other Name(s) Used: *

May we contact this employer for a reference? *

Job Duties and Responsibilities: *

Reason for Leaving: *

Discuss here any reason for lapse of employment: *

REFERENCES

Please provide at least two professional references (Supervisors, Co-workers, Teachers) and one personal reference. Family members will not be accepted as professional references.

Name *

Address *

Phone Number *

Relationship *

Email Address (if known) *

Name *

Address *

Phone Number *

Relationship *

Email Address (if known) *

Name *

Address *

Phone Number *

Relationship *

Email Address (if known) *

Name *

Address *

Phone Number *

Relationship *

Email Address (if known) *

ADDITIONAL INFORMATIONMinimum Salary Desired: *

When will you be available to begin work? *

How did you find out about this position? *

Carefully Read this Section Prior to Providing Acknowledgement Below.

I hereby affirm that information provided within this application, accompanying resume and all other supplemental information is true and complete. I acknowledge that any false or otherwise misleading representations or omissions made on said documents may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.

I understand that employment may be conditioned upon successfully passing a medical examination, and pre-hire drug screen as a condition of employment. Additionally, I understand that a criminal background review and drivers motor vehicle report may be obtained to satisfy employment requirements.

I hereby authorize persons, schools, current employers, previous employers and organizations to provide Vivant Behavioral Healthcare and/or affiliates with any requested information pertaining to my application or suitability for employment. I release all such persons or entities from any and all liability related to the providing or use of such information.

I understand that my employment is at-will which means that I am free to terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any contrary agreement to the proceeding sentence, except for a written agreement signed by Vivant Behavioral Healthcare Chief Executive Officer and notarized.

My typed name below shall have the same force and effect as my written signature.

Applicant Signature: *

Date: *

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515-316-1118
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