Alcoholism
Depression
Suicide
Indicate shifts able/willing to work: *
High School Years Completed *
College/University Years Completed
Employer 1 - Dates of Employment *
Employer 1 - May we contact this employer? *
Employer 2 - Dates of Employment *
Employer 2 - May we contact this employer? *
Employer 3 - Dates of Employment *
Employer 3 - May we contact this employer? *
Have you ever had a professional license(s) revoked/suspended, limited or censured? *
Have you ever been terminated or asked to resign from any job? *
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 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? *
Do you have a relative employed by Southwest Counseling Service or a relative who is currently a Board Member of Southwest Counseling Services? *
Have you ever plead guilty, or no contest to, or been convicted of a felony? *
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? *
Have you ever been charged with child/adult abuse or neglect? *