Employment and Jobs available at Southwest Counseling Service

How long have you been at your current address? (Years & Months) *

Please provide information on three previous addresses and length of time out lived there. *

Position applying for: *

Are you looking for a: *

Indicate shifts able/willing to work: *

High School Years Completed *

College/University Degree

College/University Years Completed

Graduate/Professional Degree

Describe Course of Study of Major

Describe Specialized Training, Experience, Skills and Extra Curricular Activities

Employer 1 - Job Title *

Employer 1 - Dates of Employment *

Employer 1 - Address *

City *

State *

Zip Code *

Employer 1 - Phone *

Employer 1 - Supervisor *

Employer 1 - Reason for leaving *

Employer 1 - May we contact this employer? *

Employer 1 - Work Performed: *

Employer 2 - Job Title *

Employer 2 - Dates of Employment *

Employer 2 - Address *

City *

State *

Zip Code *

Employer 2 - Phone *

Employer 2 - Supervisor *

Employer 2 - Reason for leaving *

Employer 2 - May we contact this employer? *

Employer 2 - Work Performed: *

Employer 3 - Job Title *

Employer 3 - Dates of Employment *

Employer 3 - Address *

City *

State *

Zip Code *

Employer 3 - Phone *

Employer 3 - Supervisor *

Employer 3 - Reason for leaving *

Employer 3 - May we contact this employer? *

Employer 3 - Work Performed: *

List each license/certification by State issued and date of expiration (if applicable):

Have you ever had a professional license(s) revoked/suspended, limited or censured? *

If yes, please provide details

Have you ever been terminated or asked to resign from any job? *

If yes, please explain circumstances

Please explain fully any gaps in your employment history

May we contact your current employer? *

Have you ever used another name? *

Is any additional information relative to change of name, use of an assumed name, or nickname necessary to enable a check on your work and educational record? *

If yes, please explain

If hired, can you provide proof that you are at least 21 years of age? *

Are you capable of satisfactorily performing the essential job duties required for the position for which you are applying? *

Do you have adequate transportation to and from work? (If applying for a position in which you must operate a company vehicle you must maintain a personal auto policy with at least State minimum limits of liability.) *

Have you ever been employed by Southwest Counseling Service? *

If yes, provide dates of employment and position held:

Do you have a relative employed by Southwest Counseling Service or a relative who is currently a Board Member of Southwest Counseling Services? *

If yes, name of person and in what capacity:

Reference 1 - Name *

Reference 1 - Address *

Reference 1 - City *

Reference 1 - State *

Reference 1 - Zip Code *

Reference 1 - Phone *

Reference 1 - Occupation *

Reference 1 - Length of Time Acquainted *

Reference 2 - Name *

Reference 2 - Address *

Reference 2 - City *

Reference 2 - State *

Reference 2 - Zip Code *

Reference 2 - Phone *

Reference 2 - Occupation *

Reference 2 - Length of Time Acquainted *

Reference 3 - Name *

Reference 3 - Address *

Reference 3 - City *

Reference 3 - State *

Reference 3 - Zip Code *

Reference 3 - Phone *

Reference 3 - Occupation *

Reference 3 - Length of Time Acquainted *

Have you ever plead guilty, or no contest to, or been convicted of a felony? *

If yes, please provide the date(s) and details

Have you been arrested for any matters for which you are out on bail or on your own recognizance pending trial? *

Have you ever been convicted of a DUI? *

If yes, how long ago

Have you ever been charged with child/adult abuse or neglect? *

Do not press submit multiple times. You will be taken to a new page once submission is complete.

EMPLOYMENT APPLICATION