1Contact Information2Basic Application Questions3Education4Employment Record5Acknowledgement6Final How did you learn about us?* Advertisement Employment Agency Friend Relative Inquiry Other Full Name* First Name Middle Last Name Mailing Address* Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Primary Phone*Secondary PhoneEmail* If you are under 18 years of age, can you provide required proof of your eligibility to work?* Yes No Have you ever filed an application with us before?* Yes No Please give date* MM slash DD slash YYYY Have you ever been employed by us before?* Yes No Please give date* MM slash DD slash YYYY Do any of your friends or relatives work here?* Yes No Please give name and relationship:*Are you currently employed?* Yes No May we contact your current employer?* Yes No Are you authorized to work within the United States?* Yes No Are you currently on lay-off status and/or subject to recall?* Yes No Can you travel if the job requires it?* Yes No Date You Can Start* MM slash DD slash YYYY What is your desired salary range? (please do not list negotiable)* Are you willing to work:* Mon-Fri 1st Shift (Full Time) Mon-Fri 2nd Shift (Full Time) Mon-Fri 3rd Shift (Full Time) Sat & Sun 1st Shift (Part Time) Sat & Sun 2nd Shift (Part Time) Sat & Sun 3rd Shift (Part Time) Are you willing to work Part Time On-Call:Part Time On-Call Any Shift Sunday Monday Tuesday Wednesday Thursday Friday Saturday Higher EducationCollege / University / Technical School Name Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Type of Degree Earned Major / Minor Course of Study Year Degree Received?* High SchoolHigh School Name Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific High School Status / Degree Level Received Diploma Received GED License / CertificationClinical Licensure?* Yes No Current Licenses LPC LCSW LMFT ALC LGSW LBSW RN LPN Other Licenses Begin with your present or most recent employment, include any job-related assignments, volunteer activities or military assignments. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or any other protected status.Previous Employer Employer Name Job Title Actions Edit Delete There are no Previous Jobs. Add Previous Job Maximum number of previous jobs reached. Please list comments, explanation of any gaps in employment:A review of the activities or job description of the position has been given. Are you capable of performing in a reasonable manner, with or without reasonable accommodation, the activities and essential functions of the job for which you have applied?Note to Applicants: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS & ESSENTIAL FUNCTIONS OF THE JOB FOR WHICH YOU ARE APPLYING. Yes No I certify the answers given herein are true and complete?* Yes No I authorize investigation of all statements contained in this application as may be necessary to arrive at employment decisions.* Yes No Acknowledgement*I understand that this application for employment shall be considered active for a period not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time shall inquire as to whether applications are being accepted. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with WellStone is of an “At Will” nature, which means that the Employee may resign at any time and the Employer may discharge the 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. Yes No 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 the rules and regulations of my employer. I understand WellStone performs pre-employment drug testing. By submitting this application, I certify that I do not have any detectable amounts of prohibited substances in my system, and understand as a condition of employment I would be asked to submit to a pre-employment drug screen. I understand if my drug screen turns out positive for prohibited substances, the offer of employment will be withdrawn and I will be ineligible for hire for a period of twelve months.Applicant’s Acknowledgement via Electronic Submission* Type out your full nameDate Acknoledged* MM slash DD slash YYYY Please read carefully*In exchange for consideration of my job application by WellStone Behavioral Health (hereinafter called the WellStone), I agree that: Neither acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position, regardless of the contents of employee handbooks, personnel manuals, benefit plans, policy statements and the like as they may exist from time to time, or to confer any right to remain an employee of WellStone or otherwise to change in any respect the “Employment At Will” relationship between WellStone and the undersigned. I further understand that the “Employment at Will” relationship cannot be altered except by written instrument signed by the CEO (and/or his designee) or the Board of Directors. Both the undersigned and WellStone may end the employment relationship at any time, without specified notice or reason. If employed, I understand that WellStone may unilaterally change or revise the benefits, policies and procedures, and with such changes may result in a reduction of benefits. I authorize investigation of all statements contained in this application. I understand that omission or misrepresentation of facts called for is cause for immediate dismissal at any time without notice. I hereby give authorization to WellStone to contact schools to verify my education, licensure boards and previous employers (unless otherwise indicated), references and I hereby release WellStone from any liability as a result of such contact. I understand that in connection with the routine processing of my application, WellStone may request from a consumer reporting agency an investigative consumer report including information as to my criminal background, credit, licensure, motor vehicle record and/or character. Upon written request from me, WellStone will provide me with additional information concerning the nature and scope of such report requested as required by the Fair Credit Reporting Act. I further understand that if employed by WellStone, my employment shall be probationary for a period of up to six months and further that any time during my probationary period or thereafter, my employment relationship with WellStone is terminable at will for any reason by either party. I agree to the above statement. WellStone is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, religion, color, gender, sexual orientation, veterans’ status, citizenship, age, disability or any other protected category. We assure you that your opportunity for employment with WellStone depends solely on your qualifications. Thank you for your interest in our organization. PhoneThis field is for validation purposes and should be left unchanged.