Avita Community Partners Employment Application

Avita Community Partners is an equal opportunity employer. It is the policy of Avita not to discriminate in hiring and employment on the basis of race, color, religion, national origin, sex, disability, age or protected class status in accordance with all applicable federal, state and local laws. No question on this application is intended to secure information for an unlawful purpose. This application will be considered active for 60 days. If you have not been employed within this period and are still interested in employment with Avita, please reapply to posted job openings at jobs@avitapartners.org. Avita Community Partners only accept applications for advertised job openings.

Incomplete applications will not be considered.

Do not answer questions with See Resume.

* indicates required fields
**All Dates should be entered in for format mm/yy.

PERSONAL INFORMATION

First Name*:
Middle Name:
Last Name*:

Street Address*:		Apt. #:
City*:		State:
Zip:		County:
Phone No.*:
Please enter a number where you can be reached between 8:00am-5:00pm. Please include area code (10 digit number).
E-mail:

JOB POSITION

Job Title and Position Number:
Please include the specific Job number, submissions with general responses or "any" will not be considered.

EDUCATION

Give record of all High Schools, Colleges, Universities and Special Schools you have attended.

NAME OF SCHOOL:
ADDRESS OF SCHOOL:
YEARS ATTENDED:(mm/yyyy)
DID YOU GRADUATE:	Yes No
GRADE COMPLETED/ DEGREE(s)/MAJOR:
SUBJECTS STUDIED:

NAME OF SCHOOL:
ADDRESS OF SCHOOL:
YEARS ATTENDED:(mm/yyyy)
DID YOU GRADUATE:	Yes No
GRADE COMPLETED/ DEGREE(s)/MAJOR:
SUBJECTS STUDIED:

NAME OF SCHOOL:
ADDRESS OF SCHOOL:
YEARS ATTENDED:(mm/yyyy)
DID YOU GRADUATE:	Yes No
GRADE COMPLETED/ DEGREE(s)/MAJOR:
SUBJECTS STUDIED:

Clinical License or Certification: Yes No
If you answer yes Type and Number is required.

Type
Number

Are you license eligible with the Georgia Composite Board of Professional Counselors, Social Workers, Marriage & Family Therapists?
Yes No

Did you complete a clinical internship? Yes No
If yes, How many hours?

Other relevant education or training (including computer and typing skills):

AVAILABILITY FOR WORK

When can you start?
(Month)
(Date)

Do you have a legal right to remain and work permanently in the United States?
(Proof of right to work will be required.)
Yes No

Are you available for full-time work? Yes No
Days Times

Are you interested in PRN/Part-time work? Yes No
Days Times

Will you work overtime if asked? Yes No

We serve 13 counties. Please put a 1 by the county that would be your first choice for employment, a 2 by your second choice, and a 3 by your third choice, etc. If you are not interested in a county put a 0 by that county:
Banks
Dawson
Forsyth
Franklin
Habersham
Hall
Hart
Lumpkin
Rabun
Stephens
Towns
Union
White

Would you consider working in other counties if a position was available?
Yes No

Would you be willing to relocate?
Yes No

GENERAL

Driver's License Number
State Issuing License

A driver cannot have six or more points against his/her license within the last five years. Cannot have had a suspended or revoked license within the last five years.

Have you ever applied to this organization before? Yes No
If yes, when?

WORK EXPERIENCE

Give chronological statement of positions held for last ten years (most recent position first). State reason for and length of inactivity between employers.

Employer's Name:
Address:
Telephone Number:	Please include area code (10 digit number).
Job Title:
From/To (mm/yy):**
Salary:

Job Duties/ Reason for Leaving
Also state reason for and length of inactivity between employers:

Can we contact your employer? Yes No

1. Were you ever terminated?
Yes No
2. Were you ever subject to disciplinary action?
Yes No
3. Were you ever promoted or the recipient of a commendation?
Yes No
If YES to any of the above three questions, please describe fully all the circumstances:

Employer's Name:
Address:
Telephone Number:	Please include area code (10 digit number).
Job Title:
From/To (mm/yy):**
Salary:

Job Duties/ Reason for Leaving:

Can we contact your employer? Yes No

1. Were you ever terminated?
Yes No
2. Were you ever subject to disciplinary action?
Yes No
3. Were you ever promoted or the recipient of a commendation?
Yes No
If YES to any of the above three questions, please describe fully all the circumstances:

Employer's Name:
Address:
Telephone Number:	Please include area code (10 digit number).
Job Title:
From/To (mm/yy):**
Salary:

Job Duties/ Reason for Leaving
Also state reason for and length of inactivity between employers:

Can we contact your employer? Yes No

1. Were you ever terminated?
Yes No
2. Were you ever subject to disciplinary action?
Yes No
3. Were you ever promoted or the recipient of a commendation?
Yes No
If YES to any of the above three questions, please describe fully all the circumstances:

Employer's Name:
Address:
Telephone Number:	Please include area code (10 digit number).
Job Title:
From/To (mm/yy):**
Salary:

Job Duties/ Reason for Leaving
Also state reason for and length of inactivity between employers:

Can we contact your employer? Yes No

1. Were you ever terminated?
Yes No
2. Were you ever subject to disciplinary action?
Yes No
3. Were you ever promoted or the recipient of a commendation?
Yes No
If YES to any of the above three questions, please describe fully all the circumstances:

Employer's Name:
Address:
Telephone Number:	Please include area code (10 digit number).
Job Title:
From/To (mm/yy):**
Salary:

Job Duties/ Reason for Leaving
Also state reason for and length of inactivity between employers:

Can we contact your employer? Yes No

1. Were you ever terminated?
Yes No
2. Were you ever subject to disciplinary action?
Yes No
3. Were you ever promoted or the recipient of a commendation?
Yes No
If YES to any of the above three questions, please describe fully all the circumstances:

Employer's Name:
Address:
Telephone Number:	Please include area code (10 digit number).
Job Title:
From/To (mm/yy):**
Salary:

Job Duties/ Reason for Leaving
Also state reason for and length of inactivity between employers:

Can we contact your employer? Yes No

1. Were you ever terminated?
Yes No
2. Were you ever subject to disciplinary action?
Yes No
3. Were you ever promoted or the recipient of a commendation?
Yes No
If YES to any of the above three questions, please describe fully all the circumstances:

Employer's Name:
Address:
Telephone Number:	Please include area code (10 digit number).
Job Title:
From/To (mm/yy):**
Salary:

Job Duties/ Reason for Leaving
Also state reason for and length of inactivity between employers:

Can we contact your employer? Yes No

1. Were you ever terminated?
Yes No
2. Were you ever subject to disciplinary action?
Yes No
3. Were you ever promoted or the recipient of a commendation?
Yes No
If YES to any of the above three questions, please describe fully all the circumstances:

Employer's Name:
Address:
Telephone Number:	Please include area code (10 digit number).
Job Title:
From/To (mm/yy):**
Salary:

Job Duties/ Reason for Leaving
Also state reason for and length of inactivity between employers:

Can we contact your employer? Yes No

1. Were you ever terminated?
Yes No
2. Were you ever subject to disciplinary action?
Yes No
3. Were you ever promoted or the recipient of a commendation?
Yes No
If YES to any of the above three questions, please describe fully all the circumstances:

MILITARY EXPERIENCE

Were you in the U.S. Armed Forces? Yes No
If yes, what branch?

Dates of duty:
From To

Rank

Duties:

PROFESSIONAL REFERENCES

Give names of at least three persons (local, if possible) who have supervised you in a professional or work capacity. Omit personal relationships and/or relatives. Please list your most recent supervisor first.

Name:
Address:
Business Phone:	Please include area code (10 digit number).

Were you supervised by this person? Yes No

Name:
Address:
Business Phone:	Please include area code (10 digit number).

Were you supervised by this person? Yes No

Name:
Address:
Business Phone:	Please include area code (10 digit number).

Were you supervised by this person? Yes No

Optional - Attach Resume/Cover Letter (200kb Max)

I authorize Avita to contact all persons, schools, and employers, current or former, to verify my employment or obtain information that may be required to arrive at an employment decision now or at any time during my employment. I permit and consent to the dissemination, transmittal and disclosure to any authorized representative of the organization and all information, medical and workers' compensation history, any governmental agency records, including federal, state, county, municipal or other records, private employer's records, private business records or any information pertaining to me that are maintained by any entity whatsoever, including criminal and employment history records. I hereby request that all entities to whom this authorization is presented, disseminate, transmit and disclose such records and information to the organization for consideration for my prospective employment or continued employment. I hereby release the organization, its agents and the aforementioned who provide such information from any liability and damages regarding the provision or use of such information.

I acknowledge that my employment may be terminated with or without cause, and with or without notice, at any time, at the option of either the organization or myself. I understand that no representative of Avita, other than the CEO of the organization, has any authority to enter into any written agreement for employment for any specified period of time or to make any agreement that contradicts or modifies the foregoing in any manner. Any written or oral statements to the contrary are hereby expressly disavowed and should not be relied upon by current or prospective employees.

I acknowledge that consent to and successful completion of a substance abuse test upon request at any time is a condition of employment and continued employment with the organization. I hereby release the organization, its agents and any individuals who administer such tests or disclose the results of such tests from any and all liability and damages resulting from the administration of, disclosure of or reliance upon the results of any tests.

I hereby declare the information provided by me in this application for employment as true, correct and complete to the best of my knowledge. I understand that if employed, any misstatement or omission of fact on this application may result in discharge.

I agree

Date Applied: