Employment Application

Maglinger Behavioral Health Services is an Equal Opportunity Employer.

Applicant Information

All fields with a '*' are required.
* First & Last Name :
* Your Address:
* Street Street 2
* City * State * Zip
* Phone:    Email: 
* Do you have a valid Driver's License?
* Date you will be available to start? : 
* Can you travel if required by this position?
* Have you ever been employed by our company?
* Can you submit proof of legal employment authorization and identity?
* Have you ever been convicted of a crime in the last 7 years?
If yes, please explain (a conviction will not automatically bar employment)


Employment History

Employer #1
All fields are required.
Employer Name:
Employer Address:
City State Zip
Employer Phone:
Immediate supervisor name:
Immediate supervisor title:
Position Held:
Start Date: End Date:
Salary:
Job summary:
Reason for leaving:


Employer #2
If applicable, All fields are required.
Employer Name:
Employer Address:
City State Zip
Employer Phone:
Immediate supervisor name:
Immediate supervisor title:
Position Held:
Start Date: End Date:
Salary:
Job summary:
Reason for leaving:


Employer #3
If applicable, all fields are required.
Employer Name:
Employer Address:
City State Zip
Employer Phone:
Immediate supervisor name:
Immediate supervisor title:
Position Held:
Start Date: End Date:
Salary:
Job summary:
Reason for leaving:




Employer #4
If applicable, all fields are required.
Employer Name:
Employer Address:
City State Zip
Employer Phone:
Immediate supervisor name:
Immediate supervisor title:
Position Held:
Start Date: End Date:
Salary:
Job summary:
Reason for leaving:


Education History

All applicable fields are required.
High School


College


Technical Training


Other


References

List 2 reference names, telephone numbers, and years known (do not include relatives or employers):
Reference #1
Name: Phone: Years known:


Reference #2
Name: Phone: Years known: