Employment Application

Name

Address

Home phone

Cell Phone

Position Sought

Social Security Number

Salary Requirement

Available start date

Type of employment desired:

Full-time Part time Temporary Seasonal

Have you ever worked for The Hendricks House Group before?

Yes No

Have you ever applied to The Hendricks House Group before?

Yes No

If yes, please explain:

Do you have any friends, relatives, and/or acquaintances working for The Hendricks House Group?

Yes No

If yes, please list name and relationship

Please list your areas of highest proficiency, special skills, or other items that may contribute to your abilities in performing the position for which you are applying

Do you speak, write, or understand any foreign language?

Yes No

If yes, which language(s) and how fluent of a speaker you cosider yourself to be

High School: Name & Location

Date of Graduation

Degree

Major/Subjects of study

College or University: Name & Location

Date of Graduate

Degree

Major/Subjects of study

Specialized Training, Trade School, etc: Name & Location

Date of Graduate

Degree

Major/Subjects of study

Other Education: Name & Location

Date of Graduate

Degree

Major/Subjects of study

Licenses

Other credentials

1. Previous Employer Name

Dates Employed

Position Title

Supervisor Name

Salary

Position Responsibilities

Reason for Leaving

2. Previous Employer Name

Dates Employed

Position Title

Supervisor

Salary

Position Responsibilities

Reason for Leaving

3. Previous Employer Name

Dates Employed

Position Title

Supervisor

Salary

Position Responsibilities

Reason for Leaving

If you are currently employed, may we contact your present employer?

Yes No

If yes, please list contact person and phone number

If hired, would you be able to present evidence of your U.S citizenship or proof of your legal right to work in the United States?

Yes No

If hired, are you willing to submit to and pass a controlled substance test?

Yes No

If hired, are you willing to submit to a background check using fingerprints?

Yes No

Do you smoke?

Yes No

Are you able to perform the functions of the position for which you are applying, either with or without reasonable accommodations?

Yes No

If no, describe the functions you cannot perform:

Are there any other areas of the job description that you cannot meet?

Yes No

If yes, what are those areas?

Please read and initial each paragraph and then sign below

I certify that i have not purposely withheld any information that might adversely affect my chances for hiring. I attest to the fact that any omission (including any misstatement) of material fact on this application or any document used to secure employment can be grounds for rejection of application or, if I am employed by The Hendricks House Group, terms for my immediate termination from The Hendricks House Group.

I understand that I am employed, my employment is not definite and can be terminated at any time either with or without prior notice and by either me or The Hendricks House Group (The Hendricks House Group is an AT WILL EMPLOYER)

I permit The Hendricks House Group to examine my references, record of employment, education record, and any other information I have provided. I authorize the references (both professional and personal) I have listed to disclose any information related to my work record and my professional experiences with them, without giving me prior notice of such disclosure. In addition, I release The Hendricks House Group, my former employers, and all other persons from any and all claims, demands, or liabilities arising out of or in any way related to such examination or revelation.

Signature

Date

OUR MISSION

The Hendricks House Group is a 501c3 organization providing Halfway House and outpatient treatment to adult men and women. Through group, individual and family therapies, the addictive person will learn how to recover from their disease and live a more responsible, productive, and healthy life. Through its interactions with the public, the Hendricks House Group will educate about addiction in an effort to promote awareness and acceptance.

Core Values
These values guide the Hendricks House Group in accomplishing our mission: Efficiency – Effectiveness – Client Satisfaction – Professionalism – Integrity

Hendricks House Group

Employment Application

OUR MISSION

PROGRAMS

ABOUT

CARF ACCREDITED

Hendricks House Group

Employment Application

OUR MISSION

PROGRAMS

ABOUT

CARF ACCREDITED

Join us as we celebrate the opening of our Millville Campus