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Clinical Job Application

Please complete the form to apply for a position with us.

First Name

Last Name

Date of Birth

Phone

Email Address

Street Address

City

Region/State/Province

Postal / Zip code

Available Start Date

Please list your DOH license number:

Please list your NPI number:

What type of employment are you looking for?

Full-Time

Part-Time

Temporary/Seasonal

If hired, can you furnish proof you are eligible to work in the U.S.?

Yes

Have you ever been convicted of any law violation (except a minor traffic violation)? If yes, please provide more detail.

Please list your education history below:

Please list your prior work experience, including the name, address, the dates you were with the company, reason for leaving, and your supervisor's contact information:

Please list 3 references, including a method of contact and your relationship to them (PLEASE NOTE: by listing these reference, I authorize the company I worked for and/or the individual listed above to release information about me to A Time To Change Counseling Center, P.A.):

Are you currently employed, if so, where?

What skills or additional training do you have that are related to the job for which you are applying?

By checking this box I certify that all information provided in this employment application is true and complete. I understand that any false information or omission may disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date. I understand that the employer may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have a right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation. I authorize the investigation of any of all statements contained in this application and also authorize any person, school, current employer (except as previously noted), past employers and organizations named in this application to provide relevant information and opinions that may be useful in making a hiring decision. I rel ease such persons and organization from any legal liability in making such statements. I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying. I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre and/or post employment drug screen as a condition of employment, if required. I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF THE EMPLOYER AND MY EMPLOYMENT MAY BE TERMINATED AT ANY TIME, WITH OR WITHOUT CAUSE AND WITH OR WITH NOTICE. I have read, understand, and by my signature consent to these statements.

By typing my name below, I attest that I have read and understand the statement above.