Application Form

Thank you for completing our application! You will have the opportunity to upload your resume and other application materials (up to 2 files) before you submit the form. If you are unable to complete the application in one session, scroll to the bottom of any page and click "Save and Continue Later." You will see a unique link where you can complete your application within 30 days.
Basic Information
Position Applied For*
Name*
First Middle Last Suffix
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Social Security Number
Email
Enter Email Confirm Email
How did you find out about this position?

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Education
Schools Attended*
Please enter institutions attended beginning with high school To add additional institutions, click on the plus sign at the end of each line.
School Attended Years Completed Diploma/Degree Major Date Graduated
Trainings and Certifications
Please list additional skills, qualifications, certifications, or licenses.

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References
References*
Please list at least three references. Click on the plus sign at the end of the line to add entries.
Name Relationship Address Phone number

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Employment History
Employer Name*
*
Start Date End Date
Job Title*
Name of Supervisor*
Employer Address*
Employer Phone*
Major Responsibilities*
Reason for Leaving*
*
Salary Start Salary End
Add another job?*
- Yes, please.
- No, I'm finished.

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Employment History
Employer Name*
*
Start Date End Date
Job Title*
Name of Supervisor*
Employer Address*
Employer Phone*
Major Responsibilities*
Reason for Leaving*
*
Salary Start Salary End
Add another job?*
- Yes, please.
- No, I'm finished.

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Employment History
Employer Name*
*
Start Date End Date
Job Title*
Name of Supervisor*
Employer Address*
Employer Phone*
Major Responsibilities*
*
Salary Start Salary End
If you have other jobs to tell us about, you'll have a chance to upload a resume at the end of this application.

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Do you speak a foreign language?*
- Yes
- No
If yes, please specify.*
Rate Your Ability*
Do you use American Sign Language?*
- Yes
- No
Rate Your Ability*

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Applicant Signature*
By typing my name below, I hereby certify that all entries in this application are true and complete, and I agree and understand that any falsification of information herein, regardless of the time of discovery, may cause forfeiture of my employment. I understand that all information on this application is subject to verification and I consent to references and former employers and educational institutions listed being contacted regarding this application.
First Last
Signature Date*
MM slash DD slash YYYY

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Equal Opportunity Employer (Confidential)
In order for Southside Behavioral Health (SBH) to assure its compliance with the Drug Free Workplace Act of 1988, please provide responses to the following questions:
Have you ever been convicted of a criminal violation involving drugs and/or alcohol abuse?*
- Yes
- No
If you answered yes, please explain. Include the respective date(s) of the conviction(s) and any subsequent action(s) involving you.*
Are you currently a participant in any allegation(s) relating to law violations involving drug and/or alcohol abuse?*
- Yes
- No
If you answered yes, please explain. Include the respective date(s) of the conviction(s) and any subsequent action(s) involving you.*
Are you currently involved as a client in an active treatment program for drug/alcohol abuse?*
- Yes
- No
If you answered 'Yes', then please explain in the space provided – Name of treatment program, time requirements and completion date*
What supportive reasonable accommodation needs will you require of SBH as they relate to your successful completion of the substance abuse treatment program?*
Please provide in the space below any other additional information you feel is related to yourself and the Drug Free Workplace Act requirements affecting employment with SBH.
Please be advised that the information you have provided on this supplemental information form will remain confidential in accordance with the provisions of the Privacy Protection Act and will not be used to discriminate in making an employment decision as applicable under Civil Rights Legislation.
Applicant Signature*
By typing my name below, I certify that the information provided in response to the questions related to SBH’s compliance with the Drug Free Work Act is complete and accurate.
First Last
Signature Date*
MM slash DD slash YYYY

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EEO-1 Self-Identification Form
The employer is subject to certain governmental record keeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites employees to voluntarily self-identify their race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. This data is for periodic government reporting and will be kept in a Confidential File separate from the Application for Employment.
Gender
Are you Hispanic or Latino?
- Yes
- No
What is your race (if you are not Hispanic or Latino as indicated above)?
Are you a military veteran?
- Yes
- No

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Other Application Materials
Please upload your resume or other application materials.
Drop files here or

Max. file size: 256 MB, Max. files: 2.
Name
This field is for validation purposes and should be left unchanged.

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Step 1 of 12

Basic Information

Education

Employment Status

References

Employment History

Employment History

Employment History

Equal Opportunity Employer (Confidential)

EEO-1 Self-Identification Form

Other Application Materials

School Attended	Years Completed	Diploma/Degree	Major	Date Graduated

Name	Relationship	Address	Phone number