Counseling Associates, Inc.

APPLICATION FOR EMPLOYMENT

Thank you for your interest in Counseling Associates, Inc. and its employment opportunities.

We will keep your application in our active applicant file for one year. During this active retention period, your application will be referred for consideration for any position for which you request interest.

If you have questions in regards to any positions, please contact Shelia Whitmore, Human Resources Coordinator at (501) 328-2222 ext 2243.

Position(s) Applied For:

Date of Application:

How Did You Learn About Us?

Employment Agency

Friend

Relative

Internet

Other

Have you ever been convicted of a felony? Yes No

PERSONAL DATA

Last Name:
First Name:
Middle Name:
Address:
City:
State:
Zip Code:
Home Phone:
Business Phone:
Message Phone:
E-Mail Address:
Social Security Number:

Some positions require shift work. Indicate the shift(s) you are available:

Day Shift

Evening

Night

Weekend Day

Weekend Night

Date Available for Work:

Salary Requested:

Have you ever been employed by or volunteered for Counseling Associates, Inc.? Yes No

If yes, when?

Have you ever applied at Counseling Associates, Inc. before? Yes No

Are any of your relatives employed by Counseling Associates, Inc.? Yes No

EDUCATION

	School Name & Location	Number of Years or Hours Completed	Diploma/Degree	Major/Minor Course of Study
High School
College
Postgraduate
Other

1. Has a federal or state office told you that you are guilty of child/elder/client abuse or neglect? Yes No

2. Are you currently under investigation for child/elder abuse or neglect? Yes No

*If yes, to either of these two questions, please explain in the space below:

Certificate or License: Is your license currently under review? Yes No

*If yes, please explain in the space below:

OCCUPATIONAL HISTORY (INCLUDE UNITED STATES MILITARY SERVICE)

LIST ALL POSITIONS HELD, STARTING WITH YOUR MOST RECENT, AND WORKING IN REVERSE CHRONOLOGICAL ORDER.

Employer:		Summary of Duties:
Number and Street:
City, State & Zip:
Title or Position:
Supervisor & Phone:
Dates Employed From:
To:
Salary:
Reason for Leaving:

Employer:		Summary of Duties:
Number and Street:
City, State & Zip:
Title or Position:
Supervisor & Phone:
Dates Employed From:
To:
Salary:
Reason for Leaving:

Employer:		Summary of Duties:
Number and Street:
City, State & Zip:
Title or Position:
Supervisor & Phone:
Dates Employed From:
To:
Salary:
Reason for Leaving:

Employer:		Summary of Duties:
Number and Street:
City, State & Zip:
Title or Position:
Supervisor & Phone:
Dates Employed From:
To:
Salary:
Reason for Leaving:

REFERENCE AUTHORIZATION

May we contact your present employer? Yes No

May we contact your former employer? Yes No

I authorize Counseling Associates, Inc., or its agents to make inquiry of my employment history. Further, I authorize persons, schools, my current employer (if stated above) and previous employers named in this application (and accompanying resume, if any) to provide relevant information as may be requested by Counseling Associates, Inc. for the purpose of making an employment decision.

I Agree: I Disagree:

READ CAREFULLY BEFORE ANSWERING

I certify that the answers given herein are true and complete to the best of my knowledge. I understand that intentionally false statements could lead to my dismissal as an employee or rejection as an applicant. I understand that a physical examination and drug test may be required prior to employment and that a job offer is conditioned on the results of the tests. I understand I may be asked to submit to periodic drug screens in the future. I understand that my employment with CAI is further conditioned on the results of the tests. I further voluntarily agree to such tests.

I understand that any employment relationship with Counseling Associates, Inc. (CAI) is of an "at will" nature, which means that the employee may resign at any time and the employer may discharge the 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 authorizing executive of CAI.

I understand that conviction of a crime may disqualify me from employment, that disqualification depends upon the relationship of the crime to the position for which I am applying, and that Counseling Associates, Inc. may request a criminal record and child abuse/neglect check following a job offer.

I have read the above information. Yes: No:

THIS SECTION IS OPTIONAL AND IS DESIGNATED TO COLLECT INFORMATION, WHICH WILL BE USED IN THE COMPLETION OF VARIOUS STATE AND FEDERAL REPORTS. THIS SECTION WILL NOT BE USED IN THE SELECTION PROCESS OR REMAIN PART OF YOUR APPLICATION.

Name:

Date:

Check one: Male Female

Please check one of the following: (Ethnic Origin)

White

Hispanic

African American

American Indian/Alaskan Native

Asian/Pacific Islander

Other

Please check if any of the following are applicable:

Vietnam Era Veteran

Disabled Veteran

Handicap Individual

Date of Birth: Social Security Number:

After submitting your application, you may also send a copy of your resume to: Shelia Whitmore, Human Resources Coordinator.