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About
Our Services
Our Philosophy
Contact
Employment
Application For Employment
NEED ACCOMMODATIONS?
If you have a disability and need reasonable accommodations to complete this form, contact Human Resources at 256-546-6324 ext. 226 OR awinkles@bridgeinc.org
APPLICATION FOR EMPLOYMENT
The Bridge is an equal opportunity employer. The Bridge does not discriminate in employment with regard to race, color, religion, national origin, citizenship status, ancestry, age, sex (including sexual harassment), sexual orientation, marital status, physical or mental disability, military status or unfavorable discharge from military service or any other characteristic protected by law. Incomplete information could disqualify you from further consideration. Please complete ALL fields.
POSITION APPLYING FOR
Position Applying For
Location of Position
PERSONAL INFORMATION
Name
First
Middle
Last
Street or Mailing Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Email Address
Home Phone
Mobile Phone
Best Time To Call
Are you legally eligible for employment in the U.S?
Yes
No
Are you at least 18 years of age?
Yes
No
Have you ever been terminated from employment or asked to resign by an employer?
Yes
No
If yes, please provide company names and details
Can you work any shift?
Yes
No
If no, explain
Can you work overtime, including weekends?
Yes
No
Are there any days that you cannot work?
Can you reliably commute or relocate?
Yes
No
Will you travel if the job requires it?
Yes
No
Have you ever submitted an application here before?
Yes
No
Date submitted
Have you ever been employed at The Bridge?
Yes
No
From
To
Are you able to perform the essential functions of the job for which you are applying, with or without a reasonable accommodation?
Yes
No
REFERRAL SOURCE
How did you find out about this position?
Employee
Bridge Web Site
Job Board (i.e. Indeed)
Educational Institution
Government Employment Agency
Walk-in
Other
EDUCATIONAL BACKGROUND
High School
Location
Degree/Diploma Completed
High School Diploma
General Education Diploma (GED)
None
Number of Years Completed
1.
College/University
Location
Major Fields of Study
Other Relevant Subjects Studied
Degree/Diploma Conferred
Yes
No
Type of Degree/Certificate
2.
College/University
Location
Major Fields of Study
Other Relevant Subjects Studied
Degree/Diploma Conferred
Yes
No
Type of Degree/Certificate
Clinical Practicum/Internship Completed
Yes
No
3.
College/University
Location
Major Fields of Study
Other Relevant Subjects Studied
Degree/Diploma Conferred
Yes
No
Type of Degree/Certificate
Clinical Practicum/Internship Completed
Yes
No
PROFESSIONAL LICENSES AND CERTIFICATES HELD
List all professional licenses or certificates.
Type of License or Certificate
License or Certification Number
Expiration Date
State
Granted By (Licensing Board)
Type of License or Certificate
License or Certification Number
Expiration Date
State
Granted By (Licensing Board)
ADDITIONAL INFORMATION
List any additional skills, knowledge, or experience you would like to be considered in assessing your qualification for this position, such as volunteer work, vocational training, computer courses, software skills, office skills, foreign language skills, keyboarding skills/speed, research skills, etc.
Additional Skills, Knowledge, or Experience
TREATMENT EXPERIENCE
List the number of years experience you have in each of the categories listed below
Substance Abuse - ADOLESCENTS
Substance Abuse - ADULTS
Substance Abuse - POST-MASTER'S
Mental Health - ADOLESCENTS
Mental Health - ADULTS
Mental Health - POST-MASTER'S
PREVIOUS EMPLOYMENT RECORD
Beginning with your present or most recent employment, list in order all positions you have held during the past 7 years. Account for period in school, military, self-employment, unemployment, or volunteer activities. Statements such as “see résumé” do not substitute for completing any portion of this application.
1.
Name of Employer
Address
Street Address
City
State / Province / Region
Beginning Date
Ending Date
Describe the type of work/Job Duties
Reason for Leaving
Supervisor
Phone
May we contact?
Yes
No
If no, why not?
2.
Name of Employer
Address
Street Address
City
State / Province / Region
Beginning Date
Ending Date
Describe the type of work/Job Duties
Reason for Leaving
Supervisor
Phone
May we contact?
Yes
No
If no, why not?
3.
Name of Employer
Address
Street Address
City
State / Province / Region
Beginning Date
Ending Date
Describe the type of work/Job Duties
Reason for Leaving
Supervisor
Phone
May we contact?
Yes
No
If no, why not?
PLEASE READ CAREFULLY BEFORE SIGNING
I understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for The Bridge to hire me. If I am hired, I understand that either The Bridge or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of The Bridge has the authority to make any assurance to the contrary. I attest with my signature below that I have given to The Bridge true and complete information on this application. No requested information has been concealed. I authorize The Bridge to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal. If I am hired, I understand that I must furnish proof of my education as indicated on my application. I also understand that if I am hired, I will be required to provide proof of identity and legal work authorization.
Applicant Name
(Required)
First
Last
Signature
(Required)
Date
(Required)
MM slash DD slash YYYY
FCRA Authorization to Obtain a Consumer Report (Background/Credit Check)
Pursuant to the federal Fair Credit Reporting Act, I hereby authorize The Bridge and its designated agents and representatives to conduct a comprehensive review of my background through a consumer report and/or an investigative consumer report to be generated for employment, promotion, reassignment or retention as an employee, internship, or volunteering. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to, the following areas: verification of Social Security number; current and previous residences; employment history, including all personnel files; education; references; credit history and reports; criminal history, including records from any criminal justice agency in any or all federal, state or county jurisdictions; birth records; motor vehicle records, including traffic citations and registration; and any other public records.
I authorize the complete release of these records or data pertaining to me that an individual, company, firm, corporation or public agency may have. I hereby authorize and request any present or former employer, school, police department, financial institution or other persons having personal knowledge of me to furnish The Bridge or its designated agents with any and all information in their possession regarding me in connection with an application of employment. internship, or for volunteering. I am authorizing that a photocopy of this authorization be accepted with the same authority as the original.
I understand that, pursuant to the federal Fair Credit Reporting Act, if any adverse action is to be taken based upon the consumer report, a copy of the report and a summary of the consumer’s rights will be provided to me.
Full Current Legal Name
(Required)
First
Middle
Last
Suffix (Jr., III, etc.)
ALL Former Names (enter N.A. if does not apply)
Maiden Name:
(Required)
Nickname(s), Alias(es), Previous Married Name(s)
(Required)
N.A.
Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Driver's License State
Number
Expiration Date
MM slash DD slash YYYY
Date of Birth
(Required)
MM slash DD slash YYYY
Signature of Applicant/Volunteer/Intern/Employee
(Required)
Date
(Required)
MM slash DD slash YYYY
VOLUNTARY SELF-IDENTIFICATION (Confidential – for statistical use only)
The Bridge, Inc. is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex, age, national origin, disability, veteran status, sexual orientation or any other classification protected by federal, state, or local law. The Bridge is subject to certain non-discrimination and affirmative action recordkeeping and reporting requirements to the Federal Government for civil rights enforcement purposes. For this reason, we invite you to self-identify. If you choose not to self-identify at this time, the government requires the employer to determine this information by visual survey and/or other available information. This information is kept separate from your application and will be used only in the compilation of data for EEO reporting. Completion of this data is voluntary and will not affect your opportunity for employment or terms or conditions of employment, if hired. When reported, data will not identify any specific individuals.
PLEASE COMPLETE IN FULL:
Date of Application
MM slash DD slash YYYY
Position for which you applied:
Name
First
Last
Gender
Male
Female
RACE/ETHNIC IDENTIFICATION (Please check one of the descriptions below corresponding to the ethnic group with which you most identify.)
American Indian or Alaskan Native
– A person having origin in any of the original peoples of North America, Central America, or South America, and who maintains tribal affiliation or community attachment.
Asian
– A person having origin in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, or Vietnam.
Black or African American
– A person having origin in any of the black racial groups of Africa.
Hispanic or Latino
– A person of Mexican, Puerto Rican, Cuban, Chicano, Central or South American, or other Spanish culture or origin, regardless of race.
Native Hawaiian or Other Pacific Islander
– A person having origin in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White
– A person having origin in any of the original peoples of Europe, North Africa, or the Middle East.
Two or More Races
– A person who primarily identifies with two or more of the above race/ethnicity categories.
I do not wish to disclose.
Personal and Confidential
This self-identification form will be separated from the application and will not be used in the employment decision.
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.