Paramount Behavioral Services

Employment Application

Please fill out this form all at once to avoid filling it out again. We recommend having your resume or other materials handy before you start, and refresh the page once before you begin. Required fields have light yellow backgrounds, but you should fill out all fields possible. You will need to complete a background check form as well.

First Name:

Middle Name or Initial:

Last Name:

Address:

City:

State:

Zip:

SSN:

Date you are available to start:

Phone:

E-mail:

Position desired:

Salary desired:

Are you a U.S. Citizen?

If no, are you authorized to work in the US?

Have you ever worked for this company?

If yes, when?

Have you been convicted of moving traffic violations related to alcohol or other drugs within the past three years?

If yes, explain.

Have you been convicted of a felony or misdemeanor criminal offense? A conviction will not necessarily disqualify an applicant from employment.

If yes, explain.

Education

High school:

Address:

Did you graduate?

Diploma?

From:

To:

College:

Address:

Did you graduate?

Degree?

From:

To:

Other:

Address:

Did you graduate?

Degree?

From:

To:

References

Please list three professional references.

First reference:

Full Name:

Company:

Relationship:

Phone:

Address:

Second reference:

Full Name:

Company:

Relationship:

Phone:

Address:

Third reference:

Full Name:

Company:

Relationship:

Phone:

Address:

Previous Employment

First job:

Company:

Address:

Phone:

Position:

From:

To:

Starting salary $

Ending salary $

Responsibilities:

Reason for leaving:

Supervisor:

May we contact your previous supervisor for a reference?

Second job:

Company:

Address:

Phone:

Position:

From:

To:

Starting salary $

Ending salary $

Responsibilities:

Reason for leaving:

Supervisor:

May we contact your previous supervisor for a reference?

Third job:

Company:

Address:

Phone:

Position:

From:

To:

Starting salary $

Ending salary $

Responsibilities:

Reason for leaving:

Supervisor:

May we contact your previous supervisor for a reference?

Military Service

Branch:

From:

To:

Rank at discharge:

Type of discharge:

If other than honorable, please explain.

Anything else you would like us to know:

Paramount Behavioral Services is an Equal Opportunity Employer. We consider all applicants for all positions without regard to race or color, sex, sexual orientation, physical or mental disability, genetic information, religion, age, ancestry or national origin, marital status or any other legally protected status.

Authorization and Signature

I certify that my answers are true and complete to the best of my knowledge. I authorize the investigation of all statements contained in this application for the purposes of evaluating my application and eligibility for employment; as such investigation may be a necessary step in arriving at an employment decision. If this application leads to employment, I understand that false or misleading information in my application or interview may result in termination of employment.

By entering my name in the SIGNATURE field provided below, I have signed the employment application.

Signature:

Today's date:

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