First name *
Middle name *
Last Name*
email*
City*
Have You been employed with us? If Yes Where?
State*
Street Address*
*Home Telephone
Zip*
Location desired to work at?
*Desired Position you would Prefer ?
County*
Business/cell telephone*
Position Desired Full-Time or Part-Time?
*Salary Desired:
*Are you a citizen of the USA?
*If you are not a USA citizen, Do you have the legal right to remain permanently in the USA?
*Do you currently have the legal right to work Here in the United States of America?
*Are you available to work extra hours if needed?
*Do you have a valid Maryland driver’s license?
*Can you provide your own transportation for field work if required?
*Other special training or skills (languages, machine operation, etc.):
Have you been convicted of any crimes in the past ten years, excluding misdemeanors and summary offenses, which have not been annulled, expunged or sealed by a court?
If Yes, you have been convicted of any crimes in the past ten years please describe in full detail what happened:
Have you ever been bonded?
If Yes, with what employers?
Do any of your relatives work here or serve on the board?
You cAN perform the essential functions of the job for you are applying, either with or without reasonable accommodation?
If You cAN not perform the essential functions for the job you are apllying for please, describe the functions that cannot be performed
Any additional information you would like to add that was related to any of the personal information you answered above?
School location?
Did you graduate?
Gradeute School name?
Degree & Major?
college Name?
College Location?
Did you Graduate?
Dedree & Major?
Business/Trade/ Technical NAme?
Business/Trade/ Technical Location?
Did you complete or graduate?
certification Name?
High School Name?
High School location?
did you GRADUATE?
diploma or ged?
Part 2 Educational information
Please give accurate, complete full-time and part- time employment record. Start with your present or most recent employer.
1. Company Name:
1. Company address:
1. Name of SUPERVISOR:
1. Company telephone:
1. Employed-(State month and year) From To:
1. Hourly or Annual Salary
1. State Job Title and Describe Your Work?
1. reason for leaving:
2. Company Name:
2. Company address:
2. Name of SUPERVISOR:
2. Company telephone:
2. Employed-(State month and year) From To:
2. Hourly or Annual Salary Start Final:
2 State Job Title and Describe Your Work?
2. reason for leavinG:
3. Company Name:
3. Company address:
3. Name of SUPERVISOR:
3. Company telephone:
3. Employed-(State month and year) From To:
3. Hourly or Annual Salary Start Final:
3. State Job Title and Describe Your Work?
3. reason for leavinG:
4. Company Name:
4. Company address:
4. Name of SUPERVISOR:
4. Company telephone:
4. Employed-(State month and year) From To:
4. Hourly or Annual Salary Start Final:
4. State Job Title and Describe Your Work?
4.reason for leavinG:
We may contact the employers listed above unless you indicate those you do not want us to contact
"Do Not Contact" Employer Number(s) and reason
Referral Source ( Website,Walk in applicant, employment agency, ADVERTISEMENT):
Did Employee referral if so Name:
Did you serve in the U.S. Armed Forces? If yes what branch and rank?
Describe any duty/training received relevant to the position for which you are applying:
PART 3 ADDITIONAL INFORMATION Membership in professional and civic organizations, special accomplishments, honors, awards, foreign languages spoken, professional licenses/certificates, job related skills, volunteer experience, etc.:
PART 4 HEALTH NOTICE The Secretary of Health and Human Services has determined that certain diseases including hepatitis A. salmonella, shigella, staphylococcus, streptococcus, and giardia may prevent you from serving food or handling food equipment in a sanitary or healthy fashion. An essential function of this job may involve handling and serving food, food service equipment and utensils in a sanitary and healthy fashion. Is there any reason why you cannot perform the essential functions of this job?
PART 5 REFERENCE CHECK your Personal reference Number?
your Personal reference Name?
your Personal reference address ?
your Personal reference Number?
your Personal reference Name?
your Personal reference address ?
Personal/Professional reference Number?
Personal/professional reference Name?
Personal/Personal reference address ?
Personal/Professional reference Number?
Personal/professional reference Name?
Personal/Personal reference address ?
Please read and understand this statement before signing your application: The information I have provided in this Application for Employment is true, correct, and complete. False, incomplete or misrepresented information of any kind will be sufficient cause for my application to be rejected or, if discovered after I am employed, cause for immediate termination of my employment.I authorize the employer to contact and obtain information about me from previous employers, educational institutions and “references” I provided, and any other party necessary to verify the accuracy of information I disclosed in this application, a related employment resume or a personal interview. To assist in the processing of my Application, I waive all rights and claims I may otherwise have against the employer or its representatives, for seeking, and using information to evaluate my employment request and all other persons, corporations or organizations who provide information for this purpose.Under Maryland law an employer may not require or demand any applicant for employment or prospective employment or any employee to submit to or take a polygraph, lie detector or similar test or examination as a condition of employment or continued employment. Any employer who violates this provision is guilty of a misdemeanor and subject to a fine not to exceed $100. This application will expire in 6 months. After that date, unless otherwise notified, I understand that my status as an applicant will end. I may re-apply for employment in the future by completing a new application. This application is not an employment agreement. If I accept an offer of employment I understand the employer may terminate my employment at any time, with or without cause and without prior notice, unless required by law. I understand that if I am employed, employment is for an indefinite period of time and that the facility can change wages, benefits and conditions at any time.Advantage Psychiatric Services LLC. is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Applicants requiring reasonable accommodation in the application and/or interview process should notify a representative of the organization.
I fully understand and accept all terms and conditions in the above statement. I fully Understand and accept the term and conditions of this application:
By writing my name below I agree that is me signing of on this application:
Date of application:
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