CBHC Employment Application - Partners Behavioral Health Management by gioAqGh

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									                                                Employment Application

                                                      Instructions to Applicant

         Thank you for your interest in Partners Behavioral Health Management. It is our policy to hire the best-qualified
         individual(s) available. Partners Behavioral Health Management serves an eight county geographic area consisting
         of Burke, Catawba, Cleveland, Gaston, Iredell, Lincoln, Surry and Yadkin Counties. Although everyone who applies
         cannot be hired, your application, if completed properly, will be given every consideration. These directions, and the
         authorization included for signature, are attached to and are intended to be a part of the application form. Partners
         Behavioral Health Management is an Equal Opportunity Employer.
         Important: Please read and comply with the following instructions and information before completing the
         Employment Application form.
         1. Use a black ink pen or complete on-line and print for signature.
         2. Give complete information on your education and work history. "See resume" is not acceptable. It is
            permissible for an applicant to attach letters of recommendation, resumes and related materials to the
            application however; resumes are NOT accepted in lieu of applications and will not be considered if submitted
            without a completed application form.
         3. List separately each job held and your duties for each position when you worked for one employer and held
            more than one position. Complete and specific information is desired. If a position was part-time, the number
            of hours per week must be entered as accurately as possible. Give complete information on the job duties
            performed in each position held.
         4. Educational detail is required and adequate space is provided in the Education Section; for example, show
            major and type of degree received. If a degree is required for the position for which you are applying, you
            must submit a transcript from the college or university attended.
         5. Review your application to ensure that all information is complete and accurate. Applications that are
            incomplete may prevent consideration for an interview and/or employment. Sign and initial the application in
            the areas requested. If not signed and initialed, your application will not be processed.
         6. Application forms are accepted for vacant and posted positions only. A separate current application form must
            be completed and submitted for each vacant position. We recommend that you keep a copy for your records.
         7. Applications are due to the Human Resources department by 5:00 PM on the closing date.
         All applicants are subject to the Drug and Alcohol Free Policies adopted by Partners Behavioral Health
         Management. This Agency is committed to a drug and alcohol free environment in which to provide services to
         those of our communities who are in need and to protect employees and the public by insuring that all of our
         employees are fit to perform their assigned duties. An applicant shall be denied employment with Partners
         Behavioral Health Management if his/her drug test is positive and any applicant who refuses to consent to a drug test
         will be denied employment with Partners Behavioral Health Management. All applicants will be subject to a pre-
         employment drug screen and a criminal record check. A motor vehicle report (driving record) is required if
         applicable for the position.

Last Name                                          First                           Middle                         Date of Application




Street Address (number and name)                                                            County



City                          State   Zip           Telephone No. ( ) Area Code

                                                    Home:           Work:           Cell:

Position Title Applied For:
Immigration Reform & Control Act                         Driver's License Information

After employment, you will be required to submit         Does the position you are applying for require a driver's license?
verification of your legal right to work in the
United States. Partners Behavioral Health                    Yes      No. If YES, you MUST provide the information below:
Management employs only United States citizens
or aliens who can provide proof of identity and                                      State                                Expiration Date
                                                               License #                         Class or Type
work authorization within 3 working days of                                         Issued                                 (mm/dd/yyyy)
employment. Partners Behavioral Health
Management participates in E-Verify.

Please list any Clinical Licensure Information or
Certifications, if required for this position
JOB RELATED EDUCATION AND TRAINING:
                                                                   Dates Attended                   Type of
                                School Address                                                     Degree or
   Name of School
                                 (City & State)                From                 To             Diploma
                                                                                                   Received        Major Subjects Studied

High School (Includes GED equivalency)                    Mo       YYYY       Mo      YYYY      (N/A if not
                                                                                                graduated)

                                                                                                                   General Studies


                                                          Mo       YYYY       Mo      YYYY      (N/A if not
Colleges or Universities
                                                                                                graduated)




                                                                                                (N/A if not
Technical, Vocational, or Military Training               Mo       YYYY       Mo      YYYY
                                                                                                graduated)



Describe job-related skills, knowledge, special training, or licenses you have pertaining to the position. Please identify skills
using computer software such as Word, Excel, PowerPoint, Access, or other specialized computer software:
                                                                                                                               Check One
                                                                                                                              Yes       No
1. Are you now, or have you ever been, employed by Partners Behavioral Health Management? If YES, identify most
recent employment dates, job title, department assigned, and/or reason for leaving in the “comments” section below.
2. Have you ever been convicted of a civil or criminal violation of the law, other than a minor traffic violation?            Yes       No
(Exclude juvenile offenses if records legally sealed). List the type of violations along with date(s) and status of
convictions in the “comments” section below. Convictions will not necessarily disqualify you from employment.
3. Have you ever been convicted of reckless driving or driving under the influence of alcohol or other drugs, OR has          Yes       No
your driver's license ever been suspended or revoked as a result of a conviction(s) of a driving violation(s)? List the
type of violations along with date(s) and status of convictions in the “comments” section below. Convictions will not
necessarily disqualify you from employment.
4. Do you have any relatives currently employed by Partners Behavioral Health Management? If yes, list their                  Yes       No
name(s), position title, department assigned, and their relationship to you in the “comments” section below.

5. Were you ever discharged or forced to resign from employment due to misconduct or unsatisfactory services? If yes,         Yes       No
explain in the “comments” section below. Prior discharges or forced resignations will not necessarily disqualify
you from employment.
6. This question is for males 18 through 25 only – Federal law requires males ages 18 through 25 to register with the         Yes       No
Federal Government to comply with the Military Selective Service Act. North Carolina GS 143B-421.1 prohibits local
governments from employing any males who have not complied with the Federal Selective Service Registration
Regulations. If this requirement pertains to you, have you complied with the Federal Law? (check the appropriate box
to the right).
Comments (for any YES answer from above, give number and explain):




 Employment Record:
Starting with previous or most recent, list all previous employers. Include self-employment and summer and part-time jobs. If more space is required,
please continue on the back of this sheet.
Last or Present Employer:                                                   Type of Organization,             Position Held:
                                                                            Government Agency, Etc.


Street Address (number and name):                                           Supervisor’s Name:                Did You Supervise Others?
                                                                                                                 Yes      No
City:                         County:              State:      Zip:         Supervisor’s Telephone            If Yes, How Many Did You
                                                                            Number:                           Supervise?

Date Employed               Date Separated         Starting Salary      Ending Salary             Reason For Leaving:
(Mo/Yr)                     (Mo/Yr)                $ per                $ per

Full Time                   Years:                 Months:              May We Contact This Employer?            Yes       No

Part Time                   Years:                 Months:              Part-Time Weekly Hours:

List Major Duties In Order Of Their Importance In The Job:




 Employment Record (Continue with next most recent employer):
Last or Present Employer:                                                   Type of Organization,             Position Held:
                                                                            Government Agency, Etc.


Street Address (number and name):                                           Supervisor’s Name:                Did You Supervise Others?
                                                                                                                 Yes      No
City:                         County:              State:      Zip:         Supervisor’s Telephone            If Yes, How Many Did You
                                                                            Number:                           Supervise?

Date Employed               Date Separated         Starting Salary      Ending Salary             Reason For leaving:
(Mo/Yr)                     (Mo/Yr)                $ per                $ per

Full Time        Years:                         Months:                 May We Contact This Employer?            Yes       No

Part Time        Years:                         Months:                 Part-time Weekly Hours:

List Major Duties In Order Of Their Importance In The Job:
 Employment Record (Continue with next most recent employer):
Last or Present Employer:                                                Type of Organization,           Position Held:
                                                                         Government Agency, Etc.


Street Address (number and name):                                        Supervisor’s Name:              Did You Supervise Others?
                                                                                                            Yes      No
City:                                County:        State:     Zip:      Supervisor’s Telephone          If Yes, How Many Did You
                                                                         Number:                         Supervise?

Date Employed               Date Separated          Starting Salary   Ending Salary           Reason For Leaving:
(Mo/Yr)                     (Mo/Yr)                 $ per             $ per

Full Time                   Years:                  Months:           May We Contact This Employer?        Yes        No

Part Time                   Years:                  Months:           Part-Time Weekly Hours:

List Major Duties In Order Of Their Importance In The Job:




Employment Record (Continue with next most recent employer):
Last or Present Employer:                                                Type of Organization,           Position Held:
                                                                         Government Agency, Etc.


Street Address (number and name):                                        Supervisor’s Name:              Did You Supervise Others?
                                                                                                            Yes      No
City:                                County:        State:     Zip:      Supervisor’s Telephone          If Yes, How Many Did You
                                                                         Number:                         Supervise?

Date Employed               Date Separated          Starting Salary   Ending Salary           Reason For Leaving:
(Mo/Yr)                     (Mo/Yr)                 $ per             $ per

Full Time                   Years:                  Months:           May We Contact This Employer?        Yes        No

Part Time                   Years:                  Months:           Part-Time Weekly Hours:

List Major Duties In Order Of Their Importance In The Job:




U.S. Military Record (Complete this section for either you or your spouse)
Branch of service in which actively served for reasons other than     From:                   To:
training:
Present military affiliation:
   None                     Reserve (active)       Reserve (inactive)                    Highest rank attained:
Kinds of training and duty while in service:




Professional/Work References:
List two past supervisors and one person who is not related to you who would have knowledge of your qualifications for the position for which you
are applying.

Name                          Title/Relationship                   Address                Phone No.               Occupation
                                                       (street, city, state, zip code)    (Include area code)




Date Available:




         If hired, I agree to conform to the policies, rules, regulations, direction and instructions of Partners Behavioral
         Health Management.

         Initials:

         I hereby certify that I have given true, accurate and complete information on this form to the best of my knowledge.
         In the event confirmation is needed in connection with my work, I authorize educational institutions, associations,
         registration and licensing boards, and others to furnish whatever detail is available concerning my qualifications. I
         authorize investigation of all statements made in this application and understand that false information or
         documentation, or a failure to disclose relevant information may be grounds for rejection of my application,
         disciplinary action or dismissal if I am employed, and (or) criminal action. I further understand that dismissal upon
         employment shall be mandatory if fraudulent disclosures are given to meet position qualifications (Authority: G.S.
         126-30, G.S. 14-122.1.) Additionally, I understand that, as a condition of employment, I will be required to
         successfully complete a pre-employment drug screen, criminal background check, and a motor vehicle report
         (driving record) if applicable for the position.



         Applicant’s Signature:                                                 Date:

								
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