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Application for Employment
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We are an equal opportunity employer, dedicated to a policy of non-discrimination in employment. All employment decisions are made without regard to age, race, sex, religion, color, national origin, physical or mental disability.
Name Social Security #
Street Address Home Phone #
City Work Phone #
State Zip Code
How did you hear about us?
Position(s) for which you are applying
Date of Application (xx/xx/xxxx)
Shift preference or Hours Available
Type(s) of Availability Full Time Part Time Temporary
  YES NO
1a) Are you at least 18 years of age?
1b) If no, can you furnish a work permit from a New Hampshire High School?
2a) Are you currently employed?
2b) If yes, may we contact your present employer?
3) Have you been convicted of any motor vehicle violations within the past five years?* (e.g. speeding tickets, loss of license, failure to stop, etc). If yes, please explain in the space below.
4. Have you ever been convicted of a felony or other crime within the past five years?* If yes, please explain in the space below. Indicate whether conviction was a misdemeanor or a felony.
*NOTE: Conviction of a motor vehicle violation or crime will not automatically result in your disqualification. The seriousness of the offense and the date of conviction will be considered in relation to the particular position(s) available or for which you have applied.
EDUCATION
Please select the highest grade you have completed
8 9 10 11 12 or GED 13 14 15 16 17 18 19 20
COLLEGE AND OTHER HIGHER EDUCATION
Please attach copies of degrees, certifications and licenses. (The privileging process at Riverbend Community Mental Health, Inc., and other affiliated healthcare organizations may require the applicant to submit transcripts at a later date.)
Name of School Major Degree of Certificate Earned
EXPERIENCE-WORK HISTORY

In the sections below, please provide a complete work history. Be sure to list your most recent experience first. If you need additional space, please attach a separate sheet of paper.
*The only part that you may substitute your resume for will be the sub-section on Position Responsibilities
Employer Telephone
Street Address City
State Zip Code
Your Job Title Supervisor (Name/Title)
Dates of Employment From (mm/yyyy) To (mm/yyyy)
Ending Pay Rate Hours Worked per Week
Please DescribeYour Position Responsibilities
How many employees did you supervise
Did you have the authority to hire/fire?
Reason you left this position
Employer Telephone
Street Address City
State Zip Code
Your Job Title Supervisor (Name/Title)
Dates of Employment From (mm/yyyy) To (mm/yyyy)
Ending Pay Rate Hours Worked per Week
Please DescribeYour Position Responsibilities
How many employees did you supervise
Did you have the authority to hire/fire?
Reason you left this position
Employer Telephone
Street Address City
State Zip Code
Your Job Title Supervisor (Name/Title)
Dates of Employment From (mm/yyyy) To (mm/yyyy)
Ending Pay Rate Hours Worked per Week
Please DescribeYour Position Responsibilities
How many employees did you supervise
Did you have the authority to hire/fire?
Reason you left this position
Employer Telephone
Street Address City
State Zip Code
Your Job Title Supervisor (Name/Title)
Dates of Employment From (mm/yyyy) To (mm/yyyy)
Ending Pay Rate Hours Worked per Week
Please DescribeYour Position Responsibilities
How many employees did you supervise
Did you have the authority to hire/fire?
Reason you left this position
Employer Telephone
Street Address City
State Zip Code
Your Job Title Supervisor (Name/Title)
Dates of Employment From (mm/yyyy) To (mm/yyyy)
Ending Pay Rate Hours Worked per Week
Please DescribeYour Position Responsibilities
How many employees did you supervise
Did you have the authority to hire/fire?
Reason you left this position
Employer Telephone
Street Address City
State Zip Code
Your Job Title Supervisor (Name/Title)
Dates of Employment From (mm/yyyy) To (mm/yyyy)
Ending Pay Rate Hours Worked per Week
Please DescribeYour Position Responsibilities
How many employees did you supervise
Did you have the authority to hire/fire?
Reason you left this position
Please list certifications and other job-related qualifications and skills.
APPLICANT'S STATEMENT

I certify that all of the above information on this application and on all other employment-related documents that I have submitted is true and complete.  I understand that any misrepresentation or omission may result in my disqualification from further consideration for employment or my termination from employment.

Further, in order that Riverbend Community Mental Health Services, Inc. may process my application for employment, I hereby authorize Riverbend Community Mental Health Services, Inc., its subsidiaries, officers, directors, employees, representatives, and agents (hereinafter collectively referred to as “Riverbend”) to conduct a complete investigation into my background including, but not limited to, inquiring into my employment history, including my fitness for duty at all prior employment; education history; credit history; criminal record and military record, if any; to obtain opinions and references regarding my moral character and reputation and to solicit and obtain any other information Riverbend in its sole discretion deems as necessary to determine my eligibility for employment or for the purposes of confirming the accuracy and completeness of any information I provided to Riverbend.  In consideration for the processing of my application for employment with Riverbend, I hereby release, indemnify and hold harmless Riverbend from any and all liability based on their authorized receipt, disclosure, and use of the information gathered in the processing of my application for employment.  I further release from liability any person or organization that provides information concerning me.

I understand that, if hired, any offer of employment is contingent on production of proof of employment eligibility and a completion of a Form I-9.  By my signature, I acknowledge that I have read and understand the foregoing and so authorize and release Riverbend.

TO BE CONSIDERED YOU MUST DIGITALLY SIGN THIS APPLICATION WITH YOUR NAME AND EMAIL ADDRESS
Name
Email
Date
 
 
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