Title: Clinical Social Worker

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Personal Details

First Name *
Last Name *
Email Address *
Social Security Number (for background check)

Contact Details

Address
City
State
Zip
Telephone
Cell phone

Qualifications

Special training skills or licenses (languages, machine operation, LCSW, CSW)?
Have you been employed with us before? Yes
No
If yes, when/where?
 
When can you start?
Pay expected
If you are under 18 years of age, can you provide required proof of eligibility to work? Yes
No
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.) Yes
No
Work Availability Full Time
Part Time
Temporary
Have you been convicted of a felony? (Conviction will not necessarily disqualify an applicant for employment.) Yes
No
If yes, please explain
Membership in professional or civic organizations (Exclude those which may disclose your race, color, religion or national group)

Education

High School
Address
From
To
 
Did you graduate? Yes
No
Degree
College
Address
From
Did you graduate? Yes
No
To
Degree
Other School/Training
Address
From
To
Did you graduate? Yes
No
Degree

Employment

Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer. Indicating “See Resume” will not be accepted.
Company
Phone
Address
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
From
To
Reason for leaving
Permission to contact previous employer for reference Yes
No

References

1. Full Name/Phone/Email/Relationship
2. Full Name/Phone/Email/Relationship
3. Full Name/Phone/Email/Relationship

Electronic Signature

* I agree that the information provided in the Application for Employment is true, correct, and complete. If employed, any misstatement or omission of fact on this application may result in dismissal. I understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ me in the future. If you decide to engage an investigative consumer reporting agency to report on my credit and personal history I authorize you to do so. If report is obtained you must provide, at my request, the name and address of the agency so I may obtain from them the nature and substance of the information contained in the report.
E-Signature
Date
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