Employment Application Position applying for: Clinician I Trauma Recovery Clinician Bi-lingual Youth Care Worker Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email Are you at least 18 years old?* Yes No State your age for child labor law purposes only.What days, shifts or hours are you available to work?*Will you be able to work overtime, if required?* Yes No When will you be able to start work?* Have you ever been convicted of any crime? A conviction does not necessarily disqualify you.* Yes No Please explain the conviction and give datesHave you ever worked in a facility that has had a license denied, revoked or suspended in any state or jurisdiction or has been the subject of a disciplinary action or been fined while employed there?* Yes No Can you, within 3 days after employment, submit documentation verifying that you are legally eligible to work in the United States?* Yes No Are you currently taking any unprescribed illegal drugs?* Yes No How did you learn of Youth Haven?*Have you ever applied or worked here before?* Yes No Specify when you previously applied or worked here.List any relatives or friends currently employed here.*List your previous employer's name.*Company's Address* Street Address Address Line 2 City State / Province / Region Company's Phone Number*Dates Employed*Name of Supervisor*Reason for leaving*State job titles and job duties*List your previous employer's name.Company's Address Street Address Address Line 2 City State / Province / Region Company's Phone NumberDates EmployedName of SupervisorReason for leavingState job titles and job dutiesList your previous employer's nameCompany's Address Street Address Address Line 2 City State / Province / Region Company's Phone NumberDates EmployedName of SupervisorReason for leavingState job titles and job dutiesPlease explain any gaps in your employment history.List any work related skills or work experience you believe are relevant to the job applied for.*Have you ever been discharged or forced to resign?* Yes No Explain why you were discharged or forced to resign.Did you receive any disciplinary notices within the last 12 months of active employment? Yes No Explain the disciplinary notice.Were you given a performance review within the last 12 months of active employment?* Yes No Explain the range of scores used and what your score wasHave you signed any non-compete agreement with any other employer that would restrict you from working with this company? Yes No Explain the non-compete agreement.Did you complete High School and receive a diploma?* Yes No If you did not reveive a diploma, did you receive a GED? Yes No List any degrees received beyond high school and the institution granting the degree.Maiden name at graduation (if applicable)List any professional licenses and/or certifications received beyond high school and the institution granting the license or certification. Please provide a copy of your current license and/or certification.Describe any additional educational skills or training you believe are relevant to the job applied for.List 5 personal references and their phone number or email*I understand that any misrepresentations, falsifications, or material omissions on this application will disqualify me from further consideration for employment and may result in my dismissal if discovered at a later date.* I understand I authorize and agree to cooperate in a thorough investigation of all statements made herein and other matters relating to my background and qualifications. I understand that any investigation conducted will include a request for employment and educational history, driving record and criminal history.* I understand I authorize any person, school, current and former employers, consumer reporting agency, and any other organization or agency to provide information relevant to such investigation, including past performance reviews, disciplinary notices received, and reason for termination, and I hereby release all persons and corporations requesting or supplying information pursuant to such investigation from all liability or responsibility to me for doing so.* I understand I understand that compliance with Youth Haven’s Employee Manual is a condition of my employment.* I understand I understand that I will 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 my employment, if required. I understand I understand and agree to conduct myself in a manner that is responsive to the beliefs, interpersonal styles, attitudes, language, and behaviors of children and families who are clients of Youth Haven, to ensure the greatest likelihood of their maximum participation in the program(s).* I understand I UNDERSTAND THAT THIS APPLICATION OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT 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 WITHOUT NOTICE.* I understand I have read, understand, and by my signature, state and certify that all information provided herein is true and correct. Sign name and date*After clicking "Submit", we will ask you to upload your resume.