Jackson Recovery - Employment Application

Jackson Recovery Centers | Life can change. We can help!

Personal Information
Name:
Last	First	MI

Other names under which you may have been employed:

Present Address:

City:	State:	Zip:
E-mail Address:
Home Phone:
Work Phone:
Message:

Position Desired

Date Available:

Shifts
Days	Full-time
Evenings	Part-time
Nights	Temporary
Rotating	On-Call

Locations

Main Office

Adolescent Center

Women & Children's Center

Satellite Office

Area:

Halfway House

Other:

Check appropriate boxes you are willing and able to accept:

Have you filed an application here before?
Yes No
If Yes, give date.

Have you ever been employed here before?
Yes No
If Yes, give date.

Are you employed now?
Yes No

How were you referred to Jackson Recovery Centers?

Recovery Centers Employee (Name):

Another Person (Name):

School (Indicate Name):

Community Organization (Please Specify):

Recruiting Agency:

Other (Please Specify):

Recovery Centers Job Post

Counselor

Newspaper Ad

Campus Visit

Professional Journal

Recruitment Fair

Education

Do you have a high school diploma or equivalency?
Yes No

If not, what is highest year completed?

Give High School, Technical School, School of Nursing, College or University, and other below if applicable to position(s) for which you are applying:

Name:
Location:
Course of Study:
Degree, Diploma, Certificate:
Date Received:

Name:
Location:
Course of Study:
Degree, Diploma, Certificate:
Date Received:

Name:
Location:
Course of Study:
Degree, Diploma, Certificate:
Date Received:

Name:
Location:
Course of Study:
Degree, Diploma, Certificate:
Date Received:

Skills
Typewriter (wpm)	Word Processing
Key Punch	10-Key Adding Machine
Dictaphone	Computer Terminal
Switchboard
Other special training or skills not mentioned above only if applicable:

Professional Licenses and/or Certificates: (i.e. nursing, chaffeur, commercial, etc.)
Type:
Active or Inactive:
State issued:
Date of Expiration:
Number:
Verified:

Type:
Active or Inactive:
State issued:
Date of Expiration:
Number:
Verified:

Type:
Active or Inactive:
State issued:
Date of Expiration:
Number:
Verified:

Employment Experience
Present Employment (or last job)
Company Name:
Address:
Name of Supervisor:
State job title and describe your work:
Telephone:
Employment dates (State month and year)
Salary (start and last)
Full or Part-time (include hrs per wk)
Reason for leaving:
May we conduct a detailed reference check and contact this employer?
Yes No Name


Present Employment (or last job)
Company Name:
Address:
Name of Supervisor:
State job title and describe your work:
Telephone:
Employment dates (State month and year)
Salary (start and last)
Full or Part-time (include hrs per wk)
Reason for leaving:
May we conduct a detailed reference check and contact this employer?
Yes No Name


Company Name:
Address:
Name of Supervisor:
State job title and describe your work:
Telephone:
Employment dates (State month and year)
Salary (start and last)
Full or Part-time (include hrs per wk)
Reason for leaving:
May we conduct a detailed reference check and contact this employer?
Yes No Name


Company Name:
Address:
Name of Supervisor:
State job title and describe your work:
Telephone:
Employment dates (State month and year)
Salary (start and last)
Full or Part-time (include hrs per wk)
Reason for leaving:
May we conduct a detailed reference check and contact this employer?
Yes No Name

Affirmative Action Policy

Jackson Recovery Centers believes in the principle and practice of Equal Employment Opportunity and will comply with the letter and spirit of applicable federal, state and local laws and regulations prohibiting employment discrimination on the basis of race, color, religion, sex, national origin, age or disability except where a bona fide occupational qualification exists reasonably necessary to the normal operations of the Recovery Centers.

I declare the statements in this application are true and accurate. I understand that my employment is subject to the results of a health screen/physical examination and satisfactorily meeting the requirements of a background check. I hereby give Jackson Recovery Centers permission to obtain references regarding my abilities and qualifications for employment and release reference source from liability concerning information on reference.

Date: Signature:

If you are a student or recent graduate in the medical field, please indicate the instructor you wish us to obtain this reference from.
Thank you.

College/School Name:

Instructor's Name:

Department:

Address:

City/State/Zip:

AN EQUAL OPPORTUNITY EMPLOYER

This application is active for six months. If you have not been hired within six months of the date of this application and wish to remain in consideration for employment, you must reapply.