Employment Application

PERSONAL INFORMATION
Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Email*
Enter Email Confirm Email
Phone*
Cell*
Referred By
Are you 18 years of age or older?*
- Yes
- No
Do you have anyone related to you working here?*
- Yes
- No
If yes, who?*
Why are you seeking employment at Hinds Behavioral Services?*
Have you ever been discharged or requested to resign from your job?*
- Yes
- No
What Company?*
If so, explain*
Have you ever been convicted of a misdemeanor or felony, to include a violation of the narcotic drug law or child abuse?*
- Yes
- No
If so, explain*

EMPLOYMENT DESIRED
List*
Position Date You Can Start Salary Desired
Are you employed now?*
- Yes
- No
If so may we inquire of your present employer?*
- Yes
- No
Ever applied to this company before?*
- Yes
- No
List
Where? When?

EDUCATION
Enter Your Education Information Starting with High School Attended*
Name & Location of School Last Year Completed? Did You Graduate? Year Graduated Degree Received

FORMER EMPLOYERS
List below your last four employers, starting with the last one first.*
Date (Ex: 01/14-08/16) Name and Address of Employer HR/Contact Telephone #'s Salary (upon leaving) Title Reason for leaving

LICENSING/CREDENTIALING
List all mental health related licensing and credentialing.*
* If Not Applicable, put N/A in each column
Type Date Received Date Renewal Due

DOCUMENTS AND AUTHORIZATION
Upload Cover Letter, Resume and References
Drop files here or

Accepted file types: pdf, doc, docx, jpg, Max. file size: 64 MB, Max. files: 5.
AUTHORIZATION: I certify that the facts contained in this application (and accompanying resume, if any) are true and complete to the best of my knowledge. I understand that any false statement, omission, or misrepresentation on this application is sufficient cause for refusal to hire, or dismissal if I have been employed, no matter when discovered by the Company. I understand that any employment is conditioned a background check. I authorize the Company to thoroughly investigate all statements contained in my application or resume, and I authorize my former employers and references to disclose information regarding my former employment, character and general reputation to the Company, without giving me prior notice of such disclosure. In addition, I release the Company, any former employers and all references listed above from any and all claims, demands or liabilities arising out of or related to such investigation or disclosure. I understand and agree that nothing contained in this application, or conveyed during any interview, is intended to create an employment contract. I further understand and agree that if I am hired, my employment will be “at will” and without fixed term, and may be terminated at any time, with or without cause and without prior notice, at the option of either myself or the Company. No promises regarding employment have been made to me, and I understand that no such promise or guarantee is binding upon the Company unless made in writing. If I am offered employment agree to submit to a medical examination and drug test before starting work. If employed, I also agree to submit to a medical examination or drug test at any time deemed appropriate by the Company and as permitted by law. I consent to such examinations and tests, and I request that the examining doctor disclose to the Company the results of the examination, which results shall remain confidential and segregated from my personnel file. I understand that my employment or continued employment, to the extent permitted by law, is contingent upon satisfactory medical examinations and drug test, and if I am hired a condition of my employment will be that I abide by the Company’s Drug and Alcohol Policy. I understand that filling out this form does not indicate there is a position open and does not obligate the Company to hire. If hired, I agree to abide by all Company work rules, policies and procedures. The Company retains the right to revise its policies and procedures, in whole or in part, at any time. If you are hired by the company, you will be required to attest to your identity and employment eligibility, and to present documents confirming your identity and employment eligibility. You cannot be hired if you cannot comply with these requirements.*
- I agree
Signature
Phone
This field is for validation purposes and should be left unchanged.

Step 1 of 6 - PERSONAL INFORMATION

PERSONAL INFORMATION

EMPLOYMENT DESIRED

EDUCATION

FORMER EMPLOYERS

LICENSING/CREDENTIALING

DOCUMENTS AND AUTHORIZATION

Contact Human Resources

Name & Location of School	Last Year Completed?	Did You Graduate?	Year Graduated	Degree Received

Date (Ex: 01/14-08/16)	Name and Address of Employer	HR/Contact Telephone #'s	Salary (upon leaving)	Title	Reason for leaving

Position	Date You Can Start	Salary Desired

Where?	When?

Type	Date Received	Date Renewal Due