Employment – Families First Counseling & Psychiatry

General Information
Position(s) Applied For*
Referral Source
- Newspaper
- Internet Search
- Employment Agency
- Friend/Relative
- Professional Journal
If Other, please explain
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Telephone*
Cell Phone
Email Address*
If under 18, can you provide a work permit?
- Yes
- No
Have you ever submitted an application here before?
- Yes
- No
If yes, give date.
MM slash DD slash YYYY
Have you ever been employed here before?
- Yes
- No
If yes, give date.
MM slash DD slash YYYY
Are you currently employed?
- Yes
- No
May we contact your employer?
- Yes
- No
Are you a United States citizen?*
- Yes
- No
Do you have a valid work permit?
- Yes
- No
Proof of citizenship or immigration status may be required upon employment.
Employment desired
You may select more than one choice by holding down the SHIFT key while you make your selection.
When are you available for work?*
MM slash DD slash YYYY
Can you travel if a job requires it?
- Yes
- No

Driver's License

(Only for positions which require driving)
Do you have a driver's license?*
- Yes
- No
Driver's license number
State of issue
Expiration Date
MM slash DD slash YYYY
Have you had any accidents during the past three years?
- Yes
- No
How many accidents?
Have you had any moving violations during the past three years?
- Yes
- No
How many moving violations?

Military
Are you a veteran of the United States military service?
- Yes
- No
If you are a veteran, what branch?
If you are a veteran, what date did you enter the military?
MM slash DD slash YYYY
If you are a veteran, what date were you discharged?
MM slash DD slash YYYY
Please describe any special skills or training acquired while in the service.

Other Special Skills
Please list other special skills you may have, e.g. fluency in other languages, licenses, special training required for the position for which you are applying, etc.

Work Experience

Please list your work experience beginning with your most recent job. If you were self-employed, give firm name. Exclude organization names which indicate race, color, creed, national origin, age, religion, sexual orientation, gender identity, gender expression, veteran status, or disability.
Most Recent Employer
Dates Employed
Employer 1 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Job Title
Supervisor
Reason for Leaving
Work Performed
May we contact your supervisor for a reference?
- Yes
- No
Starting Salary
Finishing Salary
Phone
Employer 2
Dates Employed
Employer 2 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Job Title
Supervisor
Reason for Leaving
Work Performed
May we contact your supervisor for a reference?
- Yes
- No
Starting Salary
Finishing Salary
Phone
Employer 3
Dates Employed
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Job Title
Supervisor
Reason for Leaving
Work Performed
May we contact your supervisor for a reference?
- Yes
- No
Starting Salary
Finishing Salary
Phone

References

Please list two references other than relatives or previous employers.
Name
First Last
Position
Company
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email
Phone
Name 2
First Last
Position 2
Company 2
Address 2
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email 2
Phone 2

WAIVERS AND DISCLOSURES Please read each section carefully and sign where indicated. AT-WILL EMPLOYMENT It is my understanding that this employment application, or the granting of an oral interview, does not represent a contract of employment or a promise of future benefits by this organization. I understand and agree that, if hired, my employment will be at-will in nature and may be terminated, with or without cause, at any time, by either myself or my employer. I also understand that this written statement supersedes any and all oral representations made by agents or representatives of this organization. CERTIFICATION OF TRUTH AND ACCURACY I certify that the information in this application is true, complete and correct. I understand that false answers, statements, or significant omissions made by me on this form shall be sufficient cause for denial of employment or discharge. NOTIFICATION TO CONDUCT BACKGROUND INVESTIGATION I understand that I may be subject to a background check. I understand that passing the background check is a condition of employment. A negative background check can be grounds for dismissal, even if an offer has been made to me and I have been hired. MARYLAND LAW “UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTINUED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. AN EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND SUBJECT TO A FINE NOT EXCEEDING $100.” This provision does not apply to applicants for law enforcement positions pursuant to Labor and Employment Article, Section 3-702 (b) Annotated Code of Maryland.
Type Name Here For Digital Signature
First Last
Date
MM slash DD slash YYYY

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