BHSI APPLICATION FOR EMPLOYMENT

ALL POTENTIAL EMPLOYEES ARE EVALUATED WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, AGE, MARITAL OR VETERAN STATUS, THE PRESENCE OF A NON-JOB RELATED HANDICAP OR ANY OTHER LEGALLY PROTECTED STATUS.

Position Sought: ____________________________________________________________________________

How did you learn about the position? ___________________________________________________________

Name_____________________________________________________________ Date____________________

Address__________________________________ City___________________ State________ Zip____________

Home Phone ____________________Office Phone____________________Other Phone___________________

Email Address: ______________________________ Social Security Number:___________________________

On what date would you be available for work? ____________________ Desired Wage/Salary $______________
Are you a U.S. citizen, or are you otherwise authorized to work in the U.S. without any restriction? [ ] Yes [ ] No
Have you ever been convicted of a felony? [ ] Yes [ ] No If yes, please describe circumstances: ____________
__________________________________________________________________________________________

Have you ever been convicted of a crime involving a child or vulnerable adult? [ ] Yes [ ] No If yes, please

describe circumstances: ______________________________________________________________________

Have you ever had a professional license revoked or suspended? [ ] Yes [ ] No If yes, please describe

Circumstances: ____________________________________________________________________________

Have you ever been involuntarily terminated or asked to resign from any position of employment? [ ] Yes [ ] No
If yes, please describe circumstances: _____________________________________________________________
__________________________________________________________________________________________
If selected for employment, are you willing to submit to a pre-employment drug screening test? [ ] Yes [ ] No

EDUCATION
School Name	Location	Years Attended	Degree Received	Major

Other training, certifications, or licenses held: ______________________________________________________
__________________________________________________________________________________________

List other information pertinent to the employment you are seeking: _____________________________________
__________________________________________________________________________________________

EMPLOYMENT

(Most Recent First.)

1. Employer______________________________________________ Job Title___________________________

Dates Employed______________ Prior Position Held within Company (if any): __________________________

Address__________________________________ City___________________ State________ Zip____________

Phone_____________________ Supervisor___________________________ May we contact? [ ] Yes [ ] No

Starting Salary__________________________________ Ending Salary__________________________________

Duties Performed______________________________________________________________________________

Reason for Leaving___________________________________________________________________________

2. Employer______________________________________________ Job Title___________________________

Dates Employed______________ Prior Position Held within Company (if any): __________________________

Address__________________________________ City___________________ State________ Zip____________

Phone_____________________ Supervisor___________________________ May we contact? [ ] Yes [ ] No

Starting Salary__________________________________ Ending Salary__________________________________

Duties Performed______________________________________________________________________________

Reason for Leaving___________________________________________________________________________

3. Employer______________________________________________ Job Title___________________________

Dates Employed______________ Prior Position Held within Company (if any): __________________________

Address__________________________________ City___________________ State________ Zip____________

Phone_____________________ Supervisor___________________________ May we contact? [ ] Yes [ ] No

Starting Salary__________________________________ Ending Salary__________________________________

Duties Performed______________________________________________________________________________

Reason for Leaving___________________________________________________________________________

4. Employer______________________________________________ Job Title___________________________

Dates Employed______________ Prior Position Held within Company (if any): __________________________

Address__________________________________ City___________________ State________ Zip____________

Phone_____________________ Supervisor___________________________ May we contact? [ ] Yes [ ] No

Starting Salary__________________________________ Ending Salary__________________________________

Duties Performed______________________________________________________________________________

Reason for Leaving___________________________________________________________________________

ACKNOWLEDGMENT AND AUTHORIZATION

I certify that answers given herein are true and complete to the best of my knowledge.

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 time not to exceed 45 days. 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.

____________________________________________ ___________________

Signature of Applicant Date