Job Application Job Application Position Desired Certified Addiction Counselor Director Of Operations Recovery Technician Van Driver Name * First Last * Last Email * Home Phone Mobile Phone Present Address * Present Address Street 1 Street 1 Street 2 Street 2 City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Permanent Address (if different) Permanent Address (if different) Street 1 Street 1 Street 2 Street 2 City City State/Province Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/Postal Referral Information How were you referred to Evolve Life Centers? * School Flyer Employee Co-Worker Advertisement OtherOther If Advertisement or Other please explain. Name of Co-Worker or Employee Referral General Information Have you ever been employed by Evolve Life Centers before? Yes No When and where? Have you ever been convicted of a crime, other than a minor traffic violation? Yes No Please complete the following: Date of Conviction, Place, Offense, Sentence Your answer will be only one of several factors considered in the employment decision, and will be evaluated in terms of the nature, severity and date of the offense, and on the basis of business necessity. Are you legally authorized to work in the United States? Yes No Education School High School College or University Technical Other Name Major Graduated Yes No Add Remove Other Information Please indicate any other information you think would be helpful to us in considering you for employment, such as additional skills, interests, work experience, and accomplishments. (Please exclude information indicative of age, sex, race, religion, color, national origin, ancestry, or disability). Other Information Employment History Please list your job history for the past five years (or last five employers) starting with your most recent. Please complete this section in addition to forwarding an updated resume. Employer Dates Employed Address Phone Job Title Name of Supervisor May we contact? Yes No Reason for Leaving Add Remove Licensure Regulations and Mandates require that all registered, licensed and certified employees submit proof of same to his or her employer. State License Number Status Active Expired Date of Issue Expiration Date Add Remove Has your license/certification/registration ever been under investigation? * Yes No Please explain. Availability Monday 1st Shift 2nd Shift 3rd Shift 7a-7p 7p-7a OtherOther Tuesday 1st Shift 2nd Shift 3rd Shift 7a-7p 7p-7a OtherOther Wednesday 1st Shift 2nd Shift 3rd Shift 7a-7p 7p-7a OtherOther Thursday 1st Shift 2nd Shift 3rd Shift 7a-7p 7p-7a OtherOther Friday 1st Shift 2nd Shift 3rd Shift 7a-7p 7p-7a OtherOther Saturday 1st Shift 2nd Shift 3rd Shift 7a-7p 7p-7a OtherOther Sunday 1st Shift 2nd Shift 3rd Shift 7a-7p 7p-7a OtherOther Reporting of Abuse Policy * No Yes Verbal or physical abuse, neglect, or misappropriation of client facility’s or client/resident’s property by our employees will not be tolerated. Any employee determined to have committed an act of verbal or physical abuse toward a client or resident of Evolve Life Centers IOP, LLC. / Evolve Residential, LLC. will be immediately terminated. It is every employee’s responsibility to immediately report any incidents of actual or suspected abuse to their supervisor, unless the immediate supervisor is the alleged perpetrator. In that case the report is to be made to the local Department of Human Services office immediately. Any employee who fails to immediately report any suspected abuse or neglect of a client/resident will face disciplinary action up to and including termination of employment. No reprisal act shall be taken against any employee who reports instances of client rights violation or client abuse, neglect or exploitation to the appropriate governmental authority. EEOC Policy * No Yes It is the policy of Evolve Life Centers to assure equal employment opportunity practices to all applicants and employees without regard to race, creed, color, religion, national origin, sex, disability, veteran status, marital status, or any other protected status in accordance with applicable federal, state, and local laws. This policy governs all areas of employment with Evolve Life Centers IOP, LLC. / Evolve Residential, LLC., including, but not limited to, recruiting, hiring, training, assignments, promotions, compensation, benefits, discipline and terminations. We support all employment laws regarding equal opportunity, discrimination, and affirmative action. Notifications and Acknowledgments * No Yes I hereby declare that all statements contained in this application are true and correct and that I understand that false or inaccurate information in this application may be considered grounds for immediate termination. I hereby authorize Evolve Life Centers IOP, LLC. / Evolve Residential, LLC. to investigate my applicable background history inclusive of prior employers, driving records, credentials, licenses, criminal and professional disciplinary histories, and to verify this information. I understand that if employed, my employment will not be for any fixed period of time and in “at-will” employment states either I or Evolve Life Centers IOP, LLC. / Evolve Residential, LLC. may terminate my employment at any time. I understand that I may be expected to work on a variety of job assignments within the scope of my training/credentialing, and within any geographical areas per my agreements with Evolve Life Centers IOP, LLC. / Evolve Residential, LLC. I understand that Evolve Life Centers IOP, LLC. / Evolve Residential, LLC. will attempt to assist me to expedite and maximize my recovery if I become ill or am injured in their employ, and therefore agree to accept light, or modified duty assignments that may be offered to me. I understand my failure to report to Evolve Life Centers IOP, LLC. / Evolve Residential, LLC. for work, including light and/or modified duty assignments, will indicate I have voluntarily quit, thereby relinquishing any claim for unemployment benefits. I also agree to submit to a drug screen upon request or as specified in Evolve Life Centers IOP, LLC. / Evolve Residential, LLC.’s substance abuse policy. Attach Resume Drop a file here or click to upload Choose File Maximum upload size: 268.44MB If you are human, leave this field blank. Submit
