Online Employment Application Form

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PERSONAL

DATE

SOCIAL SECURITY NUMBER

LAST NAME

FIRST NAME

MIDDLE NAME

MAIDEN NAME

Address

Address Line 1

City

State

Zip Code

HOME PHONE:

CELL PHONE:

EMAIL:

DOB:

GENDER:

POSITION(S) SEEKING

FOR EACH POSITION, PLEASE SEE THE POSITIONAL REQUIREMENTS, LIST OF HUMAN SERVICES AND RELATED FIELDS APPROVED DEGREES AND CLINICAL EXPERIENCE REQUIREMENTS PRIOR TO COMPLETING AND SUBMITTING YOUR APPLICATION.

Position(s) Seeking Availability

AVAILABLE TO WORK A FULL TIME EQUIVALENT IN THE FOLLOWING POSITION(S)
AVAILABLE TO WORK A PART TIME EQUIVALENT IN THE FOLLOWING POSITION(S)

Position(s) Seeking

INTENSIVE IN-HOME (IIH) COUNSELOR
MENTAL HEALTH SKILL-BUILDING SERVICES (MHSS) COUNSELOR
CLINICAL SUPERVISOR (LMHP-RESIDENT)
CLINICAL SUPERVISOR (LMHP-SUPERVISEE)
CLINICAL SUPERVISOR (LMHP) - LICENSED MENTAL HEALTH PROFESSIONAL

REGION

EDUCATION

EACH POSITION, PLEASE SEE THE POSITIONAL REQUIREMENTS, LIST OF HUMAN SERVICES AND RELATED FIELDS APPROVED DEGREES AND CLINICAL EXPERIENCE REQUIREMENTS PRIOR TO COMPLETING AND SUBMITTING YOUR APPLICATION.

COLLEGE:

CITY/STATE:

DEGREE:

(MM/DD/YYYY) GRADUATED:

2-COLLEGE:

2-CITY/STATE:

2-DEGREE:

2-(MM/DD/YYYY) GRADUATED:

3-COLLEGE:

3-CITY/STATE:

3-DEGREE:

3-(MM/DD/YYYY) GRADUATED:

LEGAL

ARE YOU 18 YEARS OR OLDER:

(2 FORMS OF IDENTIFICATION WILL BE REQUIRED UPON HIRE)

ARE YOU LEGALLY ELIGIBLE FOR EMPLOYMENT IN THE U.S.:

(PROOF OF CITIZENSHIP WILL BE REQUIRED UPON HIRE)

HAVE YOU EVER BEEN CONVICTED OF A CRIME OTHER THAN A MISDEMEANOR:

IF YES, PLEASE INCLUDE YOUR FULL LEGAL NAME UNDER WHICH YOU WERE CONVICTED:

EXPERIENCE

EMPLOYMENT BACKGROUND – START WITH PRESENT OR MOST RECENT POSITION AND PLEASE ONLY INCLUDE EXPERIENCE THAT MEETS THE CLINICAL EXPERIENCE REQUIREMENTS.

EMPLOYER:

MAY WE CONTACT YOUR PRESENT EMPLOYER:

JOB TITLE:

FROM (MM/DD/YYYY):

TO (MM/DD/YYYY):

OFFICE ADDRESS:

Address Line 1

City

State

Zip Code

SUPERVISOR'S NAME

SUPERVISOR’S TITLE:

TELEPHONE NUMBER:

REASON FOR LEAVING:

2nd-EMPLOYER:

2nd-MAY WE CONTACT YOUR PRESENT EMPLOYER:

2nd-JOB TITLE:

2nd-FROM (MM/DD/YYYY):

2nd-TO (MM/DD/YYYY):

2nd-OFFICE ADDRESS:

Address Line 1

City

State

Zip Code

2nd-SUPERVISOR'S NAME

2nd-SUPERVISOR’S TITLE:

2nd-TELEPHONE NUMBER:

2nd-REASON FOR LEAVING:

3rd-EMPLOYER:

3rd-MAY WE CONTACT YOUR PRESENT EMPLOYER:

3rd-JOB TITLE:

3rd-FROM (MM/DD/YYYY):

3rd-TO (MM/DD/YYYY):

3rd-OFFICE ADDRESS:

Address Line 1

City

State

Zip Code

3rd-SUPERVISOR'S NAME

3rd-SUPERVISOR’S TITLE:

3rd-TELEPHONE NUMBER:

3rd-REASON FOR LEAVING:

REFERENCES

PLEASE LIST INDIVIDUALS WHO CAN ATTEST TO YOUR ABILITIES AND WORK ACCOMPLISHMENTS

1-REFERENCE’S NAME:

1-RELATIONSHIP TO REFERENCE:

1-REFERENCE’S PHONE NUMBER:

2-REFERENCE’S NAME:

2-RELATIONSHIP TO REFERENCE:

2-REFERENCE’S PHONE NUMBER:

3-REFERENCE’S NAME:

3-RELATIONSHIP TO REFERENCE:

3-REFERENCE’S PHONE NUMBER:

ABOUT US

HOW DID YOU FIND OUT ABOUT ULLC FAMILY SERVICES:

DO YOU HAVE ANY FRIENDS/RELATIVES THAT WORK HERE:

IF YES, PLEASE LIST NAMES AND RELATIONSHIPS:

HAVE YOU APPLIED FOR A POSITION WITH US BEFORE:

WHEN (MM/DD/YYYY OF RESUME SUBMISSION):

HAVE YOU EVER BEEN HIRED BY US BEFORE:

WHEN (MM/DD/YYYY OF HIRE):

APPLICANT'S STATEMENT

APPLICANT'S STATEMENT-1

IT IS UNDERSTOOD AND AGREED UPON THAT ANY MISREPRESENTATION BY ME ON THIS APPLICATION WILL BE SUFFICIENT CAUSE FOR CANCELLATION OF THIS APPLICATION AND/OR SEPARATION FROM THE ULLC FAMILY SERVICES’ SERVICE IF I HAVE BEEN HIRED.

APPLICANT'S STATEMENT-2

I GIVE ULLC FAMILY SERVICES THE RIGHT TO INVESTIGATE ALL REFERENCES AND TO SECURE ADDITIONAL INFORMATION ABOUT ME, IF JOB-RELATED. I HEREBY RELEASE FROM LIABILITY ULLC FAMILY SERVICES AND ITS REPRESENTATIVES FOR SEEKING SUCH INFORMATION AND ALL OTHER PERSONS, CORPORATIONS OR ORGANIZATIONS FOR FURNISHING SUCH INFORMATION.

APPLICANT'S STATEMENT-3

I HEREBY UNDERSTAND AND ACKNOWLEDGE THAT, UNLESS OTHERWISE DEFINED BY APPLICABLE LAW, ANY EMPLOYMENT RELATIONSHIP WITH THIS ORGANIZATION IS OF AN “AT WILL” NATURE, WHICH MEANS THAT JUST AS I AM FREE TO RESIGN AT ANY TIME, THE EMPLOYER RESERVES THE RIGHT TO TERMINATE MY SERVICES AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE. I UNDERSTAND THAT NO REPRESENTATIVE OF THE ORGANIZATION HAS THE AUTHORITY TO MAKE ANY ASSURANCES TO THE CONTRARY.

APPLICANT'S STATEMENT-4

IN THE EVENT OF HIRE, I UNDERSTAND THAT FALSE OR MISLEADING INFORMATION GIVEN IN MY APPLICATION OR INTERVIEW(S) MAY RESULT IN DISCHARGE.

RESUME

UPLOAD RESUME & BOARD APPROVED: REGISTRATION LETTER(S), CERTIFICATION(S) AND/OR LICENSE(S)

Number of Files to Upload - (ATTN: Uploaded Files must be Microsoft Word, Apple Pages or PDF)

Add file 1

Click or drag a file to this area to upload.

SIGNATURE (TO BE SIGNED DURING FACE-TO-FACE INTERVIEW)

DATE (TO BE DATED DURING FACE-TO-FACE INTERVIEW))

Website

CONTACT US

Administrative Office

1919 Commerce Drive

Suite 300

Hampton, VA 23666

757-224-8017

757-224-8094

[email protected]

Main Office

700 Tech Center Parkway

Suite 200 – #40

Newport News, VA 23606

757-224-8017

757-224-8094

[email protected]

Online Employment Application Form

PERSONAL

POSITION(S) SEEKING

EDUCATION

LEGAL

EXPERIENCE

REFERENCES

ABOUT US

APPLICANT'S STATEMENT

RESUME

SIGNATURE (TO BE SIGNED DURING FACE-TO-FACE INTERVIEW)

DATE (TO BE DATED DURING FACE-TO-FACE INTERVIEW))

CONTACT US

MESSAGE US