Personal Information

Name: Date: *Email :

Address:

Telephone:

Are you 18 years of age or older? YesNo

Are you either a U.S. citizen or an alien authorized to work in the U.S.?YesNo

Have you ever worked or attended school under another name? If so, under what name?

Position Desired

Position: Start date available:

*Hourly wage rate desired $ :

Do you prefer:Full timePart time

Number of hours available to work per week:

What afternoon/evenings are you available to work?

Are you able to work: WeekendsHolidaysNightsOvertime

Have you previously worked for Accord Counseling LLC YesNo

Dates of employment with Accord Counseling LLC: From To

Reason(s) for leaving:

Former supervisor(s) at Accord Counseling LLC:

How did you learn about this opening?

Education

High School: Graduated?YesNo

Name of Institute: Dates attended: Course of Study:

Technical School:Graduated?YesNo

Name of Institute: Dates attended: Course of Study:

College/University:Graduated?YesNo

Name of Institute: Dates attended: Course of Study:

Post-Graduate Education:Graduated?YesNo

Name of Institute: Dates attended: Course of Study:

Other education, training or special skills:

Computer Skills

Do you own a personal laptop which can be used daily for work?YesNo

Are you experienced in using electronic health record systems (online documentation)?YesNo

Are you able to use modern Internet Browsers (ex. Safari)?YesNo

Work Experience

Please list all previous employment, beginning with the most recent.

1. Employer: Address:

Phone From To

Position Held:Reason for Leaving:

Supervisor's Name & Title:
May we contact?YesNo

Description of Duties:

2. Employer: Address:

Phone From To

Position Held: Reason for Leaving:

Supervisor's Name & Title:

May we contact?YesNo

Description of Duties:

3. Employer: Address:

Phone From To

Position Held: Reason for Leaving:

Supervisor's Name & Title:

May we contact?YesNo

Description of Duties:

References

Identify three people who know your work, beginning with the most recent.

1. Name: Phone: Email:

Address: City, State, Zip:

Position or Title: Years known:

2. Name: Phone:Email:

Address: City, State, Zip:

Position or Title: Years known:

3. Name: Phone: Email:

Address: City, State, Zip:

Position or Title:Years known:

Upload your resume (PDF, DOC, DOCX format)

Authorization and Acknowledgements

I affirm that the information I have provided in this application is true to the best of my knowledge, information and belief, and I have not knowingly withheld any information requested. I understand that withholding or misstating any information requested in this application is grounds for rejection of my application, and that providing false or misleading information in this application is grounds for discharge.
I authorize Accord Counseling to verify my references, record of employment, education record, and any other information I have provided. Unless otherwise noted, I authorize the references I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release Accord Counseling, my former employers and all other persons and entities, from any and all claims, demands or liabilities arising out of or in any way related to such inquiry or disclosure.

*Signature: Type first and last name *Date