Application Employment Application PERSONAL INFORMATION Incomplete information could disqualify you from further consideration. Name: * Name: First First Middle Middle Last Last Address: * Address: Number & Street Number & Street Address: City City State Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State Zip Code Zip Code Phone: * Home Cell Work Email: * Are you eligible for employment in the United States? * Yes No Are you 18 years of age or older? * Yes No EMPLOYMENT DESIRED * Full Time Part Time PRN Position Desired * Hourly Rate / Salary Desired * Are you able to perform the essential functions of the job for which you are applying, with or without reasonable accommodations? * Yes No Are you available to work any shift, including weekends? * Yes No If NO, what days and hours would you be available? * Are you available to work over-time (over 40 hours per week)? * Yes No Are you currently employed? * Yes No If YES, may we contact your present employer? * Yes No REFERRAL SOURCE How did you hear about us? *If you were referred to us by a current Palmer employee, please be sure to list their name. Have you ever interviewed with Palmer or its affiliates before? * Yes No Have you ever been employed by Palmer or its affiliates before? * Yes No Do you have any family and/or relative(s) employed by Palmer or its affiliates? * Yes No If YES, please list when and for what position you applied for: * If YES, please list dates and position(s) held: * If YES, please list name(s) and your relationship: * EDUCATION HighSchool Name Address Years Completed: Diploma: Yes No College Name Field of Study Years Completed: Degree: Associates Bachelors Masters Trade School Name Field of Study Years Completed: Diploma: Yes No SKILLS & QUALIFICATIONS Current Oklahoma Professional licensures, certifications, or registrations: (Check all that apply) LPC LPC U/S ODMHSAS Certified BH Case Manager LADC LADC U/S ODMHSAS Certified Pier Recovery Support Specialist LMFT LMFT U/S CDA - Child Development Associate LCSW LCSW U/S Teacher Certification RN LPN Computer and Software Skills Rate your Computer Skills: * Beginner Average Advanced Expert Rate your "Word" Skills: * Beginner Average Advanced Expert Rate your "Excel" Skills: * Beginner Average Advanced Expert Rate Your "Outlook" Skills: * Beginner Average Advanced Expert Are you bilingual? * Yes No If YES, what other languages do you speak? * List any additional skills and abilities: PROFESSIONAL REFERENCES List three professional references who are not relatives or former supervisors: Name * Phone * Occupation * Email * Years Known Name * Phone * Occupation * Email * Years Known Name * Phone * Occupation * Email * Years Known EMPLOYMENT HISTORY List all work experience beginning with your most recent employment first. Employer's Name Name of Last Supervisor Phone Address, City, State & Zip Start Date End Date Last Job Title Initial Salary Ending Salary List the performed job duties and skills: Reason for leaving: Employer's Name Name of Last Supervisor Phone Address, City, State & Zip Start Date End Date Last Job Title Initial Salary Ending Salary List the performed job duties and skills: Reason for leaving: Employer's Name Name of Last Supervisor Phone Address, City, State & Zip Start Date End Date Last Job Title Initial Salary Ending Salary List the performed job duties and skills: Reason for leaving: Employer's Name Name of Last Supervisor Phone Address, City, State & Zip Start Date End Date Last Job Title Initial Salary Ending Salary List the performed job duties and skills: Reason for leaving: CERTIFICATION & AUTHORIZATION I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that, in the event of my employment by Palmer Continuum of Care, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery. I authorize Palmer Continuum of Care to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position. I hereby give my consent to any former employer to provide employment-related information about me to Palmer Continuum of Care and will hold Palmer Continuum of Care and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information. I further authorize Palmer Continuum of Care to conduct any and all personal background checks, including but not limited to, criminal history and related records. I understand that nothing in this employment application, the granting of an interview or my subsequent employment with the Company is intended to create an employment contract between myself and the Company under which my employment could be terminated only for cause. On the contrary I understand and agree that, if hired; my employment will be terminable at will and may be terminated by me or Palmer Continuum of Care at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing. I agree to submit to a pre-employment drug screening. If employed, I will be required to provide original documents which verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of 1986. The document(s) provided will be used for completion of form I-9. I hereby acknowledge that I have read and agree to the above statements. Signature of Applicant * Date * All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, gender expression, national origin, age, protected veteran, disabled status, or genetic information. If you are human, leave this field blank. Submit Δ