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? *

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