APPLICATION FOR EMPLOYMENT PLEASE PRINT

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1 APPLICATION FOR EMPLOYMENT D.S.A. Counseling Works, LLC considers applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, sexual preference, marital or veteran status or any other legally protected status. PLEASE PRINT Position Applying For: Date: How did you hear about us? Advertisement If so, where? Inquiry Relative Employment Agency Referral If so, who? Name: (Last) (First) (M.I.) City: State: Zip Code: County: Phone Number: Alternate Number: Social Security Number: Emergency Contact Person: Phone Number: Best Time to Contact You: AM PM If less than 18 years of age, can you provide required proof of eligibility to work? Yes No Have you ever filed an application with D.S.A. Counseling Works, LLC? Yes No If Yes, when? Have you ever been employed by D.S.A. Counseling Works, LLC? Yes No If Yes, when? Do any friends or relatives work for D.S.A. Counseling Works, LLC? Yes No If Yes, his/her name Relation Are you currently employed? Yes No If Yes, may we contact your employer? Yes No Are you prevented from becoming lawfully employed in this country due to VISA or Immigration Status? Proof of citizenship or immigration status will be required upon employment. Yes No Have you ever been convicted of a crime? Yes No If necessary, attach an additional sheet and indicate See Attached Sheet

2 Offense Date City/State Disposition Date you are available to start work: Salary Desired: Hours of Availability: Are you currently in lay off status and subject to recall? Yes No Can you travel if the job requires it? Yes No EDUCATION: SCHOOL LEVEL HIGH SCHOOL COLLEGE GRADUATE OR PROFESSIONAL OTHER SCHOOLING NAME & ADDRESS COURSE OF STUDY YEARS COMPLETED DIPLOMA DEGREE WORK EXPERIENCE: Start with your present or last job. Include any job related military service assignments and volunteer activities. You may include organizations which indicate any legally protected status. Name of Employer: Supervisor s Name: Dates of Employment: Starting: Ending: Job Title: May we contact? Y N Rate/Salary: Reason for leaving: Work Performed: Name of Employer: Supervisor s Name: Dates of Employment: Starting: Ending: Job Title: May we contact? Y N Rate/Salary: Reason for leaving: Work Performed: Name of Employer: Supervisor s Name: Dates of Employment: Starting: Ending: Job Title: May we contact? Y N Rate/Salary: Reason for leaving: Work Performed:

3 Name of Employer: Supervisor s Name: Dates of Employment: Starting: Ending: Job Title: May we contact? Y N Rate/Salary: Reason for leaving: Work Performed: List below any specialized training you have had for dealing with children with emotional, behavioral and/or mental health issues: Write below any additional information you have or any supplementary skills you possess that enhance your ability to work with children and adolescents with behavioral, emotional or mental health issues.

4 APPLICANTS STATEMENT: I certify that the information and answers given here are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary to determine an employment decision. This application for employment shall be active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applicants are being accepted at the time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an at will nature. This means that the employee may resign at any time and that the employer may discharge at any time with or without cause. In the event of employment, I understand that false or misleading information given in my application and interview(s) may result in discharge. I also understand that I am required to abide by all rules and regulations of my employer. Applicant s Signature Date

5 DO NOT WRITE ON THIS SHEET APPLICATION ADDITION-FOR OFFICE USE ONLY Name of Applicant: Position Applied For: Face-to-Face Interview By: Was Applicant Hired? Yes: No: Date Applicant Reporting to Work: Pay Rate: Approval, Human Resources: Signature Date Approval, Department Head: Signature Date Orientation Date: Oriented By:

6 20 East Taunton Road, Suite #103 Berlin NJ Phone: (856) Fax;(856) Attention: Company: CONFIDENTIAL REQUEST FOR REFERENCES Title: Phone: Applicant s Name: S.S.#: Name Used While Employed: Dates of Employment From: To: Position(s) Held: Last Pay Rate: I hereby authorize you to release to D.S.A. Counseling Works, LLC any information requested concerning my employment with you. Date: Applicant s Signature: D.S.A. Counseling Works, LLC seeks to employ those applicants best suited to our child behavioral health program. The information you provide comprises one component of our selection process and will assist us in our final decision concerning the applicant. We thank you in advance for your prompt reply. All responses are confidential. Position applied for: Is the information regarding the applicant s employment with you correct? Yes No Corrections: PLEASE RATE THE APPLICANT IN THE FOLLOWING AREAS: Ability to work with others Job Knowledge Quality of Work ABOVE AVERAGE BELOW Quantity of Work Judgment Cooperation Dependability Ability to make independent decisions If terminated, employee s stated reason: Did Employees give termination notice: Yes No Comments: Date: Signature: Title:

7 20 East Taunton Road, Suite #103 Berlin NJ Phone: (856) Fax;(856) Attention: Company: CONFIDENTIAL REQUEST FOR REFERENCES Title: Phone: Applicant s Name: S.S.#: Name Used While Employed: Dates of Employment From: To: Position(s) Held: Last Pay Rate: I hereby authorize you to release to D.S.A. Counseling Works, LLC any information requested concerning my employment with you. Date: Applicant s Signature: D.S.A. Counseling Works, LLC seeks to employ those applicants best suited to our child behavioral health program. The information you provide comprises one component of our selection process and will assist us in our final decision concerning the applicant. We thank you in advance for your prompt reply. All responses are confidential. Position applied for: Is the information regarding the applicant s employment with you correct? Yes No Corrections: PLEASE RATE THE APPLICANT IN THE FOLLOWING AREAS: Ability to work with others Job Knowledge Quality of Work ABOVE AVERAGE BELOW Quantity of Work Judgment Cooperation Dependability Ability to make independent decisions If terminated, employee s stated reason: Did Employees give termination notice: Yes No Comments: Date: Signature: Title:

8 20 East Taunton Road, Suite #103 Berlin NJ Phone: (856) Fax;(856) Attention: Company: CONFIDENTIAL REQUEST FOR REFERENCES Title: Phone: Applicant s Name: S.S.#: Name Used While Employed: Dates of Employment From: To: Position(s) Held: Last Pay Rate: I hereby authorize you to release to D.S.A. Counseling Works, LLC any information requested concerning my employment with you. Date: Applicant s Signature: D.S.A. Counseling Works, LLC seeks to employ those applicants best suited to our child behavioral health program. The information you provide comprises one component of our selection process and will assist us in our final decision concerning the applicant. We thank you in advance for your prompt reply. All responses are confidential. Position applied for: Is the information regarding the applicant s employment with you correct? Yes No Corrections: PLEASE RATE THE APPLICANT IN THE FOLLOWING AREAS: Ability to work with others Job Knowledge Quality of Work ABOVE AVERAGE BELOW Quantity of Work Judgment Cooperation Dependability Ability to make independent decisions If terminated, employee s stated reason: Did Employees give termination notice: Yes No Comments: Date: Signature: Title:

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