test form b | South Central Behavioral Services

Name

First Name

First Name*

Middle Name

Middle Initial

Last Name

Last Name*

Former Names/Aliases used

State Born in *

Address:

Street

Street*

City

City*

State

State*

Zip

Zip*

Daytime Phone

Daytime Phone*

Evening Phone

Evening Phone*

Email Address

Email Address*

Cover Letter (250 char max):

Indicate which position you are applying for, including full or part time:*

Do you have a valid Nebraska Driver's License?*

Do you have an NPI (National Provider Identification) number?*

Have you ever applied or worked at SCBS in the past?*

Do you have any friends or relatives working for SCBS*

Are you available to work weekends?*

Are you available to work on holidays?*

Are you available to work nights?*

Are you available to work overtime?*

Are you available to travel on agency business?*

Have you in the past 10 years been convicted of a felony? If yes, please explain.*

If yes, please explain.

NOTE: No applicant will be denied employment solely based on the grounds of a conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for, may however, be considered.

Have you ever been convicted of any crime, including sex-related or child abuse-related? If so, please explain. *

If yes, please explain.

NOTE: No applicant will be denied employment solely based on the grounds of a conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for, may however, be considered.

Do you speak, write or understand any language other than English?*

If so, what language(s)?

Educational History:

High School:*

Address:*

Area of Study:*

Post High School*

Location*

Degree*

Major*

Minor*

Date of Graduation:*

Dates Attended:*

Post High School:*

Location*

Degree*

Major*

Minor*

Date of Graduation:*

Dates Attended:*

Please list any significant certifications, licenses, courses, honors and awards that feel would be relevant to the position you are interested in:

How did you hear about us or this job opening? *

Employment History:

Please fill in the name of the most recent to the least recent Employer/Supervisor, your job title, dates you worked and a brief description of your job responsibilities and your reason for leaving.

Place of Employment: *

Name of Employer/Supervisor:*

Job Title:*

Dates of Employment:*

Job Responsibilities:*

Reason for Leaving:*

Place of Employment: *

Name of Employer/Supervisor:*

Job Title:*

Dates of Employment:*

Job Responsibilities:*

Reason for Leaving:*

Place of Employment: *

Name of Employer/Supervisor:*

Job Title:*

Dates of Employment:*

Job Responsibilities:*

Reason for Leaving:*

Place of Employment: *

Name of Employer/Supervisor:*

Job Title:*

Dates of Employment:*

Job Responsibilities:*

Reason for Leaving:*

Professional Associations and Organizations.
Include any positions held and your responsibilities

Personal References:

Personal Reference - NAME:*

Address:*

City, State, Zip:*

Daytime Phone Number:*

Evening Phone Number:*

Previous Employer Reference:

Previous Employer Reference - NAME:*

Address:*

City, State, Zip:*

Evening Phone Number:*

Professional Reference:

Professional Reference - NAME:*

Address:*

City, State, Zip:*

Evening Phone Number:*

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