Employment Application – Still Waters Professional Counseling Services, Inc.

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Today's Date:

MM slash DD slash YYYY

APPLICANT'S INFORMATION

Name:

First Middle Last Suffix

Address:

Street Address City State / Province / Region ZIP / Postal Code

Phone 1 (Mobile):

Phone 2 (Other):

Email:

Social Security Number:

Do you have reliable transportation?

Yes

Are you able to provide proof of vaccination if you are hired?

I am fully vaccinated and have proof.

I am partially vaccinated, pursing completion of vaccination and have proof.

I am not vaccinated but I am willing to be vaccinated.

I am not vaccinated due to a medical or religious reason and can provide exsemption proof.

I am not vaccinated and do not wish to be vaccinated for any reason.

Note: In accordance with the mandate set forth by Centers for Medicare and Medicaid Services (CMS), healthcare workers employed at facilities that accept Medicare or Medicaid must now provide proof of vaccination status to employers.

Are you a citizen of the U.S.A.?

Yes

If no, answer next queston.

Are you authorized to work in the U.S.A.?

Yes

Have you ever been convicted of a felony?

Yes

If the answer is yes, please explain.

Explanation of felony:

Do you have a clean driving record?

Yes

If no, please explain. (Particularly list any DUI's)

Explanation of driving record (DUI's):

Is there anything on a background check that would disqualify you from working with us?

Yes

If yes, please explain.

Explanation of disqualifying factors:

Are you able to perform the job without reasonable accommodation?

Yes

Explain reasonable accommodation.

Reasonable accommodation:

POSITION(S) APPLYING FOR

Position(s) Applying For:

How did you hear about this position?

Facebook

Indeed

Still Waters Employee

Government Job Site

Hiring Event

Recruiter

Still Waters Website

Monster Jobs

ZipRecruiter

Newspaper

Online Search

Other

If hired, when would you be able to start?

MM slash DD slash YYYY

Salary or Hourly Requirement

Salary

Hourly Rate

Please check one and indicate amount.

Salary or Hourly Requirement Amount:

Other terms, notes or expectations:

Have you ever worked for Sill Waters before?

Yes

If the answer is yes, please indicate when.

Previous Still Waters employment date:

MM slash DD slash YYYY

MILITARY SERVICE

Have you served in the military?

Yes, but now discharged

Yes, and currently still serving

If yes, please answer the following:

Country served:

Military Service Start Date:

MM slash DD slash YYYY

Military Service End Date:

MM slash DD slash YYYY

Branch:

Rank at Discharge:

Type of discharge?

Honorable Discharge

General Discharge under Honorable Conditions

Other than Honorable Discharge

Bad Conduct Discharge

Dishonorable Discharge

Entry-Level Separation

Medical Seperation

Seperation for Convenience of the Government

Provide explanation for discharge:

Explanation of Discharge:

EDUCATION - HIGH SCHOOL

High School History:

Graduated High School

Attended did not Graduate High School

Year Graduated High School:

Last grade completed:

Name of High School:

High School Location:

City State / Province / Region

EDUCATION - COLLEGE, UNIVERSITY OR TECHNICAL SCHOOL

Have you attended College, University or Technical School?

Yes

If yes, please indicate the details below.

1) College, University or Technical School

1) Name of School:

1) Address

Street Address City State / Province / Region ZIP / Postal Code Country

1) Did you graduate?

Yes

1) Date Started:

MM slash DD slash YYYY

1) Date Completed:

MM slash DD slash YYYY

1) Degree

1) Did you complete an internship for your degree?

Yes

2) College, University or Technical School

2) Name of School:

2) Address

Street Address City State / Province / Region ZIP / Postal Code Country

2) Did you graduate?

Yes

2) Date Started:

MM slash DD slash YYYY

2) Date Completed:

MM slash DD slash YYYY

2) Degree

2) Did you complete an internship for your degree?

Yes

3) College, University or Technical School

3) Name of School:

3) Address

Street Address City State / Province / Region ZIP / Postal Code Country

3) Did you graduate?

Yes

3) Date Started:

MM slash DD slash YYYY

3) Date Completed:

MM slash DD slash YYYY

3) Degree

3) Did you complete an internship for your degree?

Yes

PREVIOUS EMPLOYMENT

1) Employer

1) Company Name:

1) Supervisor's Name:

First Last

1) May we contact this previous supervisor for a reference?

Yes

1) Company Phone:

1) Company Address:

Street Address City State / Province / Region ZIP / Postal Code Country

1) Job Title:

1) Job responsibilities:

1) Reason for leaving:

1) I was paid …

… a salary

… by the hour

1) Starting Salary or Hourly Rate

1) Ending Salary or Hourly Rate

2) Employer

2) Company Name:

2) Supervisor's Name:

First Last

2) May we contact this previous supervisor for a reference?

Yes

2) Company Phone:

2) Company Address:

Street Address City State / Province / Region ZIP / Postal Code Country

2) Job Title:

2) Job responsibilities:

2) Reason for leaving:

2) I was paid …

… a salary

… by the hour

2) Starting Salary or Hourly Rate

2) Ending Salary or Hourly Rate

3) Employer

3) Company Name:

3) Supervisor's Name:

First Last

3) May we contact this previous supervisor for a reference?

Yes

3) Company Phone:

3) Company Address:

Street Address City State / Province / Region ZIP / Postal Code Country

3) Job Title:

3) Job responsibilities:

3) Reason for leaving:

3) I was paid …

… a salary

… by the hour

3) Starting Salary or Hourly Rate

3) Ending Salary or Hourly Rate

4) Employer

4) Company Name:

4) Supervisor's Name:

First Last

4) May we contact this previous supervisor for a reference?

Yes

4) Company Phone:

4) Company Address:

Street Address City State / Province / Region ZIP / Postal Code Country

4) Job Title:

4) Job responsibilities:

4) Reason for leaving:

4) I was paid …

… a salary

… by the hour

4) Starting Salary or Hourly Rate

4) Ending Salary or Hourly Rate

5) Employer

5) Company Name:

5) Supervisor's Name:

First Last

5) May we contact this previous supervisor for a reference?

Yes

5) Company Phone:

5) Company Address:

Street Address City State / Province / Region ZIP / Postal Code Country

5) Job Title:

5) Job responsibilities:

5) Reason for leaving:

5) I was paid …

… a salary

… by the hour

5) Starting Salary or Hourly Rate

5) Ending Salary or Hourly Rate

REFERENCES

I hereby authorize any former employer or references that I provide on my application to disclose in good faith any information they may have regarding my qualifications and fitness for employment to Still Waters Professional Counseling Services, Inc. I will hold anyone giving references on my behalf free of liability for the exchange of this information and any other reasonable and necessary information to the employment process.(Required)

I Authorize.

Reference 1

1) Reference Name

First Last

1) Relationship

1) Company

1) Phone

1) Location

City State / Province / Region

Reference 2

2) Reference Name

First Last

2) Relationship

2) Company

2) Phone

2) Location

City State / Province / Region

Reference 3

3) Reference Name

First Last

3) Relationship

3) Company

3) Phone

3) Location

City State / Province / Region

EXPERIENCE, DIGITAL SOFTWARE, SPECIAL SKILLS, AWARDS, CERTIFICATES

Can you operate a computer?

Yes

Somewhat but need more training

If yes, answer next question.

Select the computer platforms you have used and are comfortable with:

MAC

Other

Select any digital software that you are experienced or comfortable working with:

Microsoft Word

Microsoft Excel

Microsoft Powerpoint

Microsoft Office

Outlook

Teams

Calendar

Sharenote (EHR)

BambooHR

Adobe Photoshop

Adobe Illustrator

Adobe Indesign

Wordpress

Have you ever worked with Electronic Health Records?

Yes

Somewhat but need more training

If yes, list the EHRs you have experience with:

Electronic Health Record platforms that I have experience with:

Do you speak or read other languages than the English Language?

Yes

Somewhat but need more training

If yes, list the languages.

List any languages you speak or read fluently:

List any experience, special skills, awards or certificates that we should know about.

DISCLAIMER AND SIGNATURE

I understand that I am applying to work in an organization that provides community-based counseling or case management to individuals. This position will require traveling in the community and visiting homes to provide direct care (in the form of therapy or skill-building) inside the homes of clients based on my credentials and scope of practice. By signing this form, I acknowledge that I am willing to enter into individuals' homes to provide treatment and care based on their treatment plans.(Required)

I understand and agree.

Consent

I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.

Signature