Current Opening: Licensed Therapist, Click for Description

EMPLOYMENT APPLICATION

Name

First Name

Last Name

Other Name(s):

Provide any additional information relative to change of name or nickname necessary to enable a check on your work or school record.

Position Applying For:

Date Available

Phone

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

CERTIFICATIONS/LICENSURES

Type:

Number:

Expiration:

Endorsement(s):

Education

Undergraduate Degree

College / University Location

Dates

Degree/Credential

Major

Minor

Graduate

COMPLETE SET OF UNOFFICIAL TRANSCRIPTS REQUIRED/OFFICIAL TRANSCRIPTS ARE REQUIRED UPON EMPLOYMENT (administrative, teaching, and counseling positions only)

WORK EXPERIENCE: List work experience in chronological order. If more space is needed, continue on a separate sheet.

Employer

City/County

State

Job Responsibility

Dates Mo./Day/Yr. (From – To)

Ending Salary

Reason for Leaving

AFFILIATIONS

List any professional organizations with which you are currently a member

ACTIVE MILITARY EXPERIENCE

Branch of Service:

Dates of Service:

Honorable Discharge?

Yes

REFERENCES It is the applicant’s responsibility to submit at least three references and must include current employer (if employed) or last employer (if unemployed). Do not use relatives.

Please Include: Name, Title, Organization, Street Address, City, State, Zip, and Telephone Phone

PERSONAL BACKGROUND

Are you currently under contract?

Yes

If so, where?

Please add the date to be released from contract along with your present position title.

Have you ever been refused tenure or a continuing contract? (If yes, explain below)

Have you ever been suspended, discharged or requested to resign from a position? (If yes, explain below)

Have you ever had a certificate or license revoked or suspended? (If yes, explain below)

CRIMINAL HISTORY

Have you ever entered a plea of guilty or no contest to a state or federal felony charge?

Have you ever been convicted of a state or federal felony offense?

Have you ever been charged with a state or federal felony offense that was reduced to a misdemeanor offense which you entered a plea of guilty or nolo contendre?

Have you ever entered a plea of guilty or no contest, or been convicted of, a state or federal misdemeanor charge involving illegal chemical substances or illegal sexual activity?

If yes to any of the above, complete the following: Type of Violation, Date, and Place (City, State)

PROOF OF EMPLOYABILITY, BACKGROUND CHECK AND DRUG/ALCOHOL TEST

Any applicant chosen for employment must be able to produce a social security card, driver's license, or some other acceptable form of verification of employment eligibility in the United States pursuant to Form I-9 of the U.S. Department of Justice. Any offer of employment, oral and written, is contingent on Street School's verification of credentials and references, an acceptable criminal background, and a clean drug/alcohol test. I certify that the statements in this application are true, complete, and not misleading to the best of my knowledge, and I authorize investigation of all statements contained herein. I hereby release from all liability any persons or organizations furnishing such information. I understand that I will be subject to disqualification or dismissal if any statement in this application is found to be untrue. Include Electronic Signature of Applicant and Date