South Central Behavioral Services : Employment Application

Employment Application

Please fill out the following form. All fields with an asterisk (*) must be completed. Please put NA if not applicable.

Today's Date

Month*	Day*	Year*

Name

Last Name*	First Name*	Middle Initial

Address:

Street*	City*	State*	Zip*


Daytime Phone*	Evening Phone*

Email Address*

Cover Letter (250 char max):

Indicate which position you are applying for, including full or part time:*

Do you have a valid Nebraska Driver's License?*

Have you ever applied or worked at SCBS in the past?*

Do you have any friends or relatives working for SCBS?*

Are you available to work weekends?*

Are you available to work on holidays?*

Are you available to work nights?*

Are you available to work overtime?*

Are you available to travel on agency business?*

Have you in the past 10 years been convicted of a felony? If yes, please explain.*

Have you ever been convicted of any crime, including sex-related or child abuse-related? If yes, please explain.*

NOTE: No applicant will be denied employment solely based on the grounds of a conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for, may however, be considered.

Do you speak, write or understand any language other than English? If so, what language(s)?*

How did you hear about us or this job opening?*

Educational History:

High School:*
Address:*
Area of Study:*

Post High School:*
Location:*
Degree:*
Major:*
Minor:
Date of Graduation:*
Dates Attended:*

Post High School:*
Location:*
Degree:*
Major:*
Minor:
Date of Graduation:*
Dates Attended:*

Please list any significant certifications, licenses, courses, honors and awards that feel would be relevant to the position you are interested in:

Employment History:
Please fill in the name of the most recent to the least recent Employer/Supervisor, your job title, dates you worked and a brief description of your job responsibilities and your reason for leaving.

Employer/Supervisor:*
Job Title:*
Dates of Employment:*
Job Responsibilities and Reason for Leaving:*

Employer/Supervisor:*
Job Title:*
Dates of Employment:*
Job Responsibilities and Reason for Leaving:*

Employer/Supervisor:*
Job Title:*
Dates of Employment:*
Job Responsibilities and Reason for Leaving:*

Employer/Supervisor:*
Job Title:*
Dates of Employment:*
Job Responsibilities and Reason for Leaving:*

Professional Associations and Organizations.
Include any positions held and your responsibilities:

Technical or Computer Skills.
Use this area to describe any technical or computer-based skills. Include software you are familiar with and your proficiency level:

Personal References:
Name:*
Address:*
City, State, Zip:*
Daytime Phone Number:*
Evening Phone Number:*

Previous Employer Reference:
Name:*
Address:*
City, State, Zip:*
Daytime Phone Number:*
Evening Phone Number:*

Professional Reference:
Name:*
Address:*
City, State, Zip:*
Daytime Phone Number:*
Evening Phone Number:*

Additional Information:

Use this area to include any additional information you may wish us to consider. (250 char max)

Attach resume here (2MB Limit):

Please enter the anti-spam code:

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