Bootheel Counseling Services is an Equal Opportunity Employer Position Applied For: Today's Date: Name (f/m/l): Address: Telephone: Home: Cell: Social Security Number: Email address (optional): Best time and telephone number to contact you is: Have you ever filed an application with us before? Y N If yes, give date: Y N Have you ever been employed with us before? If yes, give date: N Y Do any of your friends or relatives, other than spouse, work here? If yes, state name, relationship and location: Y Are you currently employed? N May we contact your present employer? N Y Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status?  (Proof of citizenship or immigration status will be required upon employment.) Y N What is your desired salary range? Date available for work: Are you available to work: Full Time Part Time Temporary Are you currently on "lay-off" status and subject to recall? Y N Can you travel if a job requires it? N Y Skills: Please indicate any of the following with which you have had direct experience: PC Typing Words Per Minute Microsoft Word Microsoft Excel Microsoft Publisher PowerPoint Copier Fax 10-Key Calculator Other: Please list other skills you possess which are relevant to the position for which you are applying: Education: Associate's GED/High School Bachelor's Master's Ph.D. M.D. Name of School(s) & Major(s): Associate's Degree Bachelor's Degree Master's Degree Other Degree(s) Name of Certificate(s) and Expiration: Name of License(s) and Number(s): Employment Experience: (please start with your current or most recent job) JOB #1: Employer: Address: Telephone: Job Title: Supervisor: Reason for leaving: To: Dates employed: From: Work performed: JOB #2: Employer: Address: Telephone: Job Title: Supervisor: Reason for leaving: Dates employed: From: To: Work performed: JOB #3: Employer: Address: Telephone: Job Title: Supervisor: Reason for leaving: Dates employed: From: To: Work performed: Have you ever been convicted of or pleaded no contest to any criminal charges (other than motor vehicle speeding violations) brought against you?  If yes, please provide full explanation, including resolution of charges. Y Explain: N Have you ever been convicted of or pleaded no contest to a drug or alcohol related offense?  If yes, please provide full explanation. Y N Explain: Personal/Professional References: (do not include family members or past supervisors) Name Phone Number Best Time to Call Occupation/Relationship 1. 2. 3. Applicant's Statement: By submitting this electronic application, I certify that answers given herein are true and complete.   I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of six months.  Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause.  It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.  I understand also, that I am required to abide by all rules and regulations of the employer.