APPLICATION FOR EMPLOYMENT

What Position are you applying for?

Select * Administrative (Records, Billing, Reception, etc.)Outpatient Behavioral Health TherapistPositive Behavior Support SpecialistPerson-Centered CoachCommunity Access SpecialistOTHER Name * Email * Phone * Previous Address (Address, City, State, Zip) * Current Address (Address, City, State, Zip) * Notify in case of an emergency (Name and Telephone number) *

Have you lived outside of Kentucky in the last year?

Select PLEASE SELECTYESNO If Yes, Which state?

For purposes of compliance with the Immigration Reform and Control Act, are you leally eligible for employment within the United States

Select PLEASE SELECTYESNO

Under the Immigration Report and Control Act off 1986, you will be required to fill out a certification verifying that you are eligible to be employed and verifying your identify. Further, you will be required to provide documentation to that effect, should you be employed.

List any relatives employed by a community mental health/intellectual disability center or program.

EDUCATION AND TRAINING

GIVE COMPLETE INFORMATION FOR ALL YOUR EDUCATION AND TRAINING. IF YOU COMPELTED COLLEGE WORK, YOU MAY E REQUESTED TO FURNISH AN OFFICIAL TRANSICRIPT OF ALL COMPLETED WORK.

WHAT IS THE HIGHEST GRADE COMPLETED?

IF YOU DID NOT COMPLETE HIGH SCHOOL, DO YOU HAVE A HIGH SCHOOL EQUIVALENCY DIPLOMA?

Select PLEASE SELECTYESNO HOW MANY YEARS DO YOU AHVE OF POST HIGH SCHOOL EDUCATION? NAME OF INSTITUTION, LOCATION, HOURS, DEGREE RECIEVED, MAJOR/MINOR LIST SCHOLSTIC HONORS

EMPLOYMENT HISTORY

BEGIN WITH PRESENT OR LAST JOB AND DESRIBE ACCURATELY THE DUTIES OF EACH POSITION.

MAY WE CONTACT YOUR PRESENT EMPLOYER REGARDING YOUR QUALIFICATIONS?

Select PLEASE SELECTYESNO

Current/Most Recent Job

Date of Employment From * To * Starting Salary * Ending Salary * Description of Duties * Employer Supervisor’s Name Address Phone Number

JOB 2

Date of Employment From * To * Starting Salary * Ending Salary * Description of Duties * Employer Supervisor’s Name Address Phone Number

PERSONAL REFERENCES (PLEASE NO RELATIVES)

Name, Address, Phone, Occupation, Number of years known Name, Address, Phone, Occupation, Number of years known Name, Address, Phone, Occupation, Number of years known

HAVE YOU EVER BEEN CONVIECTED OF LAW VIOLATIONS, INLCUDING MOVING TRAFFIC VIOLATIONS, BUT EXCLUDING OFFENSES BEFORE YOU EIGHTEENTH (18TH) BIRTHDAY WHICH WERE ADJUDICATED IN A JUVENILE COURT OR UNDER A YOUTH OFFENDER LAW?

Select YESNO IF YES, PLEASE EXPLAIN

THIS AGENCY WILL REQUIRE ALL EMPLOYEES HAVE A CRIMINAL RECPRDS CJECL TP BE COMPLETED BY THE KENTUCKY STATE POLICE AND/OR OTHER GOVERNING AGENCIES AT THE POINT OF EMPLOYMENT.

WOULD YOU PROVIDE YOUR OWN TRANSPORTATION IF NECESSARY FOR YOUR EMPLOYMENT?

Select PLEASE SELECTYESNO WHAT DATE ARE YOU AVIALABLE TO START WORK? *

I HEREBY CERTIFY THAT ALL ENTRIES ON THIS APPLICATION AND ATTACHMENTS ARE TRUE AND COMPLETE AND I AGREE AND UNDERSTAND THAT ANY FALISIFICATION OF INFORMATION HEREIN, REGARDLESS OF TIME OF DISCOVERY, MAY CAUSE FORFIETURE ON MY PART ON ANY EMPLOYMENT IN THE AGENCY. I UNDERSTAND THAT ALL INFORMATION IN THIS APPLICATION IS SUBJECT TO VERIFICATION AND I CONSENT TO REFERENCES, FORMER EMPLOYERS, AND EDUCATIONAL INSTITUTIONS LISTED BEING CONTACTED REGARDING INFORMATION RECIEVED FORM SUCH CONTACTS. THE AGENCY EXECUTIVE DIRECTOR OR CHIEF EXECUTIVE OFFICER MAY DISSEMINATE INFORMATION CONTACTED ON THIS APPLICATION TO OTHER AGENCIES, NON-GOVERNMENTAL ORGANIZATIONS, OR SYSTEMS ON A NEED-TO-KNOW BASIS FOR GOOD CAUSE SHOW AS DETERMINED.

SIGNATURE OF APPLICANT (TYPE LEGAL NAME HERE) * Date *