Southeast Missouri Behavioral Health

Southeast Missouri Behavioral Health Employment Application

Employment Application If you are interested in applying, please fill out the following and click Submit at the bottom of the page. Please do not hit Enter while the cursor is outside of a textbox, as this will hit the Submit button and submit the information filled out. NOTICE TO ALL APPLICANTS As part of our pre-employment procedures, you will be required to successfully complete a urine drug test. You will also be required to fill out certain pre-employment forms at the time of your interview. This application will remain active for no more than 90 days from the date it was made. Southeast Missouri Behavioral Health does not deny employment or services because of race, sex, color, creed, marital status, national origin, disability, or age of applicants or employees.

Personal Information
Your Email Address
First Name
Middle Initial/Name
Last Name
Maiden Name
Phone
Secondary Phone
Present Address
Present City
Present State
Present Zip Code
Permanent Address
Permanent City
Permanent State
Permanent Zip Code
Check if you are 21 years or older
Check if you are a US citizen or an alien authorized to work in the United States
The Age Discrimination in Employment Act of 1987 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.

In case of emergency notify
Name
Phone
Address
City
State
Zip
Relationship

Employment Desired
Position Applying For	Director Physician Community Education Specialist Licensed Professional Counselor Licensed Clinical Social Worker Registered Nurse Clinical Manager Accounting/Business Information Technology Behavioral Health Technician/Aide Clerical Group Facilitator Substance Abuse Counselor Food Service Worker Maintenance Community Support Specialist Other (please list):
Availability	Full Time Part Time PRN Temporary
Date you can start
Salary/Pay desired
Have you ever applied to SEMO BH before?
How long ago did you apply?
At what location did you apply?
Have you been employed previously by SEMO BH?
Are you employed now?
If so, may we inquire of your employer?
Referred by
Do you know anyone at this company? (leave blank for none, list the name if yes)
Are you related to anyone at this company? (leave blank for none, list the name if yes)
Have you ever been convicted of a felony? Answering Yes will not automatically disqualify you from employment
If Yes, please explain

Education
	Name and Location of School	Number of years attended	Did you graduate?	Subjects Studied
Grammar School
High School
College
Graduate School
Trade, Business, or Correspondence School

General
Subjects of special study or research work
Special Skills
Keyboarding Words per Minute:	10 Key Entry
Microsoft Access	Microsoft Word
Microsoft Excel
Any other software with which you are familiar
Any other skills you feel would be applicable
Professional licenses and number information
Professional certificates and expiration
Any other relevant training
Activities (civic, athletic, etc.) Exclude organizations, the name of which indicates the race, creed, sex, age, marital status, color, or nation of origin of its members
U.S. Military or Naval Service Rank
Present membership in National Guard or Reserves

Former Employers

List below your last four employers, starting with the last one first

Date, Month and Year	Name, Address, and Phone Number of Employer	Salary	Position	Reason for Leaving
From To
From To
From To
From To

Which of these jobs did you like the best and why?

Personal References

Give the names and phone numbers of three persons not related to you, whom you have known at least one year.

Name	Phone Number	Address	Years Aquainted

This agency is required by Federal Law to report specific information regarding our applicant pool for our Affirmative Action Program. The completion of each item is strictly voluntary. The information will be used exclusively for our internal monitoring and reporting to Federal agencies. Your cooperation is greatly appreciated. NOTE: None of the information supplied below will be used in the employment process. This information will be separated from the application and will be used exclusively in our reporting requirements to the Federal Agencies.
Ethnic Origin:	American Indian/Alaskan Native - A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition. If American Indian/Alaskan Native, please designate tribal affiliation:
Date of Birth:	Gender:
Veteran Status:	Do you claim coverage under the Americans with Disabilities Act (ADA)?
I decline to answer these voluntary questions:

By clicking submit I certify that the facts contained in my application for employment with Southeast Missouri Behavioral Health, Inc., are true and complete to the best of my knowledge and understand that if employed, falsified statements on the application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed on my application and/or any other documents given for pre-employment purposes to give you any and all information concerning my previous employment and any pertinent information they may have. By clicking submit below I hereby release forever all parties from all liability for any damage that may result from furnishing the same to you. I understand and fully agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice and without cause.