Eastern Shore Psychological Services



Eastern Shore Psychological Services, LLC

Application for Employment

Today’s date [pic] Social Security Number [pic] [pic] [pic]

Print Name [pic]

Position applied for [pic]

Salary requirements [pic]

Address [pic]

Street or PO Address City County State Zip Code

Home phone [pic] [pic] [pic] Work Phone [pic] [pic] [pic]

Email address [pic]

Preferred Site(s) Salisbury Princess Anne Easton Chestertown

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It is the policy of Eastern Shore Psychological Services to provide equal employment opportunities for all qualified individuals; and, to prohibit discrimination in employment on any basis protected by applicable state or federal law, including but not limited to race, color, religious creed, marital status, sex, sexual orientation, ancestry, national origin, age, medical condition, disability, or veteran status. Eastern Shore Psychological Services promotes equal employment opportunities in all aspects of employment through positive employment policies and practices. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.

Section A – INSTRUCTIONS TO APPLICANT

1. Please fully and accurately complete the Application for Employment. Incomplete applications will not be considered. ESPS will use the information given in the application to verify your previous employment and background.

2. Resumes will not be accepted in lieu of completed applications, but will be considered supplemental information

3. If you are hired, proof of citizenship or immigration status will be required to verify your lawful right to work in the United States.

Section B – GENERAL INFORMATION

1. Have you filed an application with this company before?

yes no If yes, approx. date [pic]

2. Have you been employed with this company before?

yes no If yes, approx. date [pic]

3. Have you ever gone by another name?

yes no If yes, please list name [pic]

4. If employed in the position for which you have applied, would you be in a supervisor / subordinate relationship to any relative or member of your household? yes no

5. Have you ever been discharged or asked to resign from any previous employment?

yes no If yes, please explain [pic]

6. If you are hired or transferred into a position that requires the operation of a vehicle, we will require a Dept. of Motor Vehicles (DMV) investigation. Do you authorize investigation of your DMV record? yes no

Driver’s license number [pic] State [pic] Exp. Date [pic]

7. Have you ever been convicted of any violation of the law other than minor traffic violations?

yes no If yes, give date, place of conviction, charge and disposition:

[pic]

8. Are you currently under any obligation pursuant to an existing contract of employment, or for payment of placement fees to an employment service? yes no

If yes, please explain [pic]

9. How were you referred to us? Advertisement Agency Other – specify [pic]

Section C– WORK EXPERIENCE

Please fill out the application completely, even if doing so duplicates your resume, beginning with your current or most recent employment. Attach additional sheets as needed.

|Company Name |  |  |Dates employed -- Month & Year |Job Title |  |  |  |

| | |  |  |From: | |To: |  |

| | |  |  |From: | |To: |  |

| | |  |  |From: | |To: |  |

| | |  |  |

  |  |  |  |  |  |  |  |  |  |  |  | |  | | |  |  | |  |  |  |  | |  | |  |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  |  | |  | | |  |  | |  |  |  |  | |  | |  |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  |  | |  | | |  |  | |  |  |  |  | |  | |  |  |  |  |  |  |  |  |  |  |  |  | |  |  |  |  |  |  |  |  |  |  |  |  | |  | | |  |  | |  |  |  |  | |  | |  |  |  |  |  |  |  |  |  |  |  |  | |

1. Please list computer software skills:

[pic]

2. List any special licenses or certifications you have that are related to the job for which you are

applying:

[pic]

Section F – PROFESSIONAL INFORMATION (If applicable)

1. Professional licensure [pic] Number [pic]

Effective License Date(s) [pic] State [pic]

2. Registry or certification [pic] Number [pic]

Effective Registry/ Certification Date(s) [pic] State [pic]

3. Is your registration or license pending? yes no

If your answer is "yes", please explain: [pic]

4. To your knowledge, are you currently the subject of a complaint or are you under investigation by any professional Licensure or registration body? yes no

5. Has your license ever been suspended or revoked or have you otherwise been reprimanded, disciplined or sanctioned by any professional licensure or registration body? yes no If your answer is "yes", please explain:

[pic]

6. Are you currently the subject of any criminal or other charges that could affect your license or registration to practice in your profession if found meritorious? yes no

If your answer is "yes", please explain:

[pic]

7. Is any non-compete, non-solicitation, nondisclosure, or similar agreement applicable to your current activities? yes no

If your answer is "yes," attach a copy of the agreement to this application.

Section G – AUTHORIZATION

“I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references and employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release the company from all liability for any damage that may result from utilization of such information.

I also understand and agree that no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing, unless it is in writing and signed by an authorized company representative.

This waiver does not permit the release or use of disability-related or medical information in a manner prohibited by the Americans with Disabilities Act (ADA) and other relevant federal and state laws."

Signature of applicant__________________________________________Date_______________

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