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Application

INSTRUCTIONS: If you need help filling out this application form or for any phase of the employment process, please notify the person who gave you this form and every reasonable effort will be made to meet your needs in a reasonable amount of time.

-Please read “Applicant Note” below.
-Complete all pages of this application.
-Application will be valid for 60 days.

APPLICANT NOTE: This application form is intended for use in evaluating your qualifications for employment with us. This is not an employment contract. Please answer all appropriate questions completely and accurately. False or misleading statements during the interview and on this form are grounds for terminating the application process or, if discovered after employment begins, terminating employment. All qualified applicants will receive consideration and will be treated throughout their employment without regard to race, color, religion, sex, national origin, age, disability, or any other protected class status under applicable law. Additional testing for the presence of illegal drugs in your body MAY be required prior to employment.

General Information

First Name

Middle Name

Last Name

Date of Birth

Position Applying For

Social Security Number

Phone Number

Alternate Phone Number

Current Address

City

State

Zip Code

Previous Address

City

State

Zip Code

Driver's License

Valid Drivers License #

State Issued

Exp. Date

Make and Model of Vehicle

Year of Vehicle

Auto In. Company

Policy #

Expiration Date

Emergency Contacts

First Name

Middle Name

Last Name

Phone Number

First Name

Middle Name

Last Name

Phone Number

Do you have any impairments that could interfere with your ability to do your job? Yes / No If yes, explain?

If yes, explain?

How did you hear about Life Anew Behavioral Health Inc?

Have you have been given a copy of the job description for the position for which you have applied to review?

Are you able to perform the essential functions of the job for which you are applying with or without a reasonable accommodation?

Why are you interested in employment with us?

Due to the nature of the business, no guarantee can be made as to the schedule or the amount of hours worked.

What date are you available to begin work?

Availability

Monday

Times

Tuesday

Times

Wednesday

Times

Thursday

Times

Friday

Times

Sunday

Times

Saturday

Times

Are you willing to provide service to a client with a pet?

If yes, which ones:

Dogs Cats Both

Are you willing to provide service to a client that smokes?

*For employment our minimum education requirement is either a GED or High School diploma

Highest Level of Education

Most Recent Employer

Are you Currently Working for this Employer?

May we contact them?

Company Name

Phone Number

Job Title

Supervisors Name

Duties

State

Zip Code

City

Dates Employed

Salary

Reason for Leaving:

Second Recent Employer

Company Name

Phone Number

Supervisors Name

Job Title

Duties

State

Zip Code

City

Dates Employed

Salary

Reason for Leaving:

Third Recent Employer

Company Name

Phone Number

Supervisors Name

Job Title

Duties

State

Zip Code

City

Dates Employed

Salary

Reason for Leaving:

*******Please be sure to complete the attached Authorization to do a criminal and motor vehicle background check.

As a condition of employment all employees must be “Bondable & “Insurable”. Are you at least 19 years of age?

List states and counties of residence for the past seven years:

Have you had any moving traffic violations?

If yes, explain:

Have you been charged/convicted of a felony and/or misdemeanor/or served time?

If yes, please describe:

Have you ever been a charged perpetrator or appeared on any child abuse registry in the last 5 years?

Please complete all three references. Your application will not be considered unless three references are provided. Since we will contact these references, please notify them in advance.
If we are unable to reach all 3 references, you will be asked to provide additional references.

First Name

Last Name

Phone Number

Best Time to Contact?

Relationship?

Number of Years Known?

First Name

Last Name

Phone Number

Best Time to Contact?

Relationship?

Number of Years Known?

First Name

Last Name

Phone Number

Best Time to Contact?

Relationship?

Number of Years Known?

Upload Cover Letter

Upload Resume

Acceptance

CERTIFICATION AND RELEASE: I certify that I have read and understand the applicant note on page one (1) of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts in this application may result in rejection of my application or discharge at any time during my employment. I authorize Life Anew Behavioral Health, Inc., and/or its agents, including consumer-reporting bureaus, to verify any of this information including, but not limited to, criminal history and motor vehicle driving records. I authorize all persons, schools, companies and law enforcement authorities to release any information concerning my background and hereby release any said persons, schools, companies and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I release Life Anew Behavioral Health, Inc from any liability which might result from making such investigations. I also understand that the use of illegal drugs is prohibited during employment. I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment. I understand that this application is not a contract of employment. My employment is contingent upon confirmation of credentials and successful completion of drug test or criminal background check. I also understand that if hired, regardless of any oral presentations to the contrary, the employment relationship between Life Anew Behavioral Health, Inc., and myself is terminable at-will, so that both the company and I remain free to choose to end out work relationship at any time for any or no reason. Any changes in this employment relationship must be made in writing. I also understand that due to the nature of the business, no amount of work can be guaranteed.

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