Application – Salisbury Behavioral Health

Name *

First

Last

Social Security

Address *

City *

State *

Zip Code *

Email *

Phone *

Best number to reach you.

Are you authorized to work in the United States? *

Have you been a resident of PA for the past 24 consecutive months? *

Have you ever been employed by Salisbury Behavioral Health, Inc., Milestones Community Healthcare, Inc., New Story, LLC, PAHrtners Deaf Services, LLC, or Growth Horizons, Inc.? *

If yes, which office?

Dates of Employment:

Position Held:

How were you referred to the Company? *

If referred by an employee, list employee name:

List the position(s) for which you are applying: *

High School *

Address *

Years completed *

Did you graduate? *

Indicate type of Degree or Diploma *

High School Diploma / GED

Business /Trade/Tech

Address

Course of Study/Major

# of years completed

Did you graduate?

Indicate type of Degree or Diploma

(AAS, BA/BS, MA/MS, etc.)

College

Course of study/major

#of years completed

Did you graduate?

Indicate type of Degree or Diploma

(AAS, BA/BS, MA/MS, etc.)

Graduate

Address

Course of study/major

# of years completed

Did you graduate?

Indicate type of Degree or Diploma

(AAS, BA/BS, MA/MS, etc.)

Licenses/Certifications:

List any licenses (including driver’s license), certificates, or professional associations which relate to, or is a requirement of, the position for which you are applying.

License Number

State

Year Issued

Expiration Date

Licenses/Certifications:

List any licenses (including driver’s license), certificates, or professional associations which relate to, or is a requirement of, the position for which you are applying.

License Number

State

Year Issued

Expiration Date

Previous Employer *

Employment History (Please give accurate, complete full-time and part-time employment record, beginning with your present or most recent employer. Do not indicate “See resume”.)

Phone *

Address *

Dates of Employment *

Name of Supervisor *

Ending Salary *

Position *

Reason for Leaving *

Job Responsibilities *

May we contact this employer for a professional reference? *

Previous Employer *

Employment History (Please give accurate, complete full-time and part-time employment record, beginning with your present or most recent employer. Do not indicate “See resume”.)

Phone *

Address *

Dates of Employment *

Name of Supervisor *

Ending Salary *

Position *

Position (copy) *

Reason for Leaving *

Job Responsibilities *

May we contact this employer for a professional reference? *

Previous Employer *

Employment History (Please give accurate, complete full-time and part-time employment record, beginning with your present or most recent employer. Do not indicate “See resume”.)

Phone *

Address *

Dates of Employment *

Name of Supervisor *

Job Responsibilities *

Reason for Leaving *

Ending Salary *

May we contact this employer for a professional reference? *

Professional Reference 1 *

Title *

Company Name and Address *

Reference Phone Number *

Professional Reference 2 *

Title *

Company Name and Address *

Reference Phone Number *

Professional Reference 3 *

Title *

Company Name and Address *

Reference Phone Number *

Have you ever been disciplined or terminated from employment for abuse or neglect of an individual under your care? *

If yes, please explain.

Have you ever been convicted of a crime? *

If yes, please explain.

Do you have criminal charges pending against you *

If yes, please explain.

The information provided on this Application for Employment is true, correct, and complete. It is understood and agreed upon that any misrepresentation by me in this application will be sufficient cause for cancellation of this application and/or termination from employment if I am subsequently employed. I give Salisbury Behavioral Health, Inc. the right to investigate all references and to secure additional information about me, including criminal background clearance, child abuse clearance, FBI clearance, motor vehicle records, etc. as deemed necessary and appropriated by the Company for the position(s) for which I am applying. I hereby release from liability Salisbury Behavioral Health, Inc. and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. Salisbury Behavioral Health, Inc. is an Equal Opportunity Employer. Salisbury Behavioral Health, Inc. participates in E-Verify to confirm employment eligibility. *

Signature

Are any of the following pending against you? *

If yes, please explain.

I certify that the above information is true and accurate.

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