Employment Application

To be considered for a position, please fill out our application below. Please note that if you leave this page and come back, your information will not be saved.

You may also download an application here:

Application for Employment

Applicant Information
Date*
Date Format: MM slash DD slash YYYY
Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Email
Date Available
Date Format: MM slash DD slash YYYY
SS#
Desired Salary
Position(s) and Position Number(s) Applying for*
Are you authorized to work in the United States?*
- Yes
- No
Have you ever worked for this company?*
- Yes
- No
If so, when?
Are you currently employed?*
- Yes
- No
If yes, why are you pursuing a change?*
Have you ever been dismissed from a State of Georgia position, or any other employer?*
- Yes
- No
If yes, please attach explanation.
Do you speak any language(s) other than English?*
- Yes
- No
If yes, please list.
Do you have a relative, partner, member of your household or in a dating relationship with someone that works at Behavioral Health Services of South Georgia?*
- Yes
- No
If yes, where does this person work?
Education
Graduated from High School or Obtained GED?*
- Yes
- No
You will be asked to provide transcripts.
High School Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Attended From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Did you graduate?
- Yes
- No
Degree
College
Major
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Attended from
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Did you graduate?
- Yes
- No
Degree
Other
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Attended From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Did you graduate?
- Yes
- No
Degree
Have you completed any special courses, seminars, and/or training that would enable you to perform the duties for the position for which you are applying?
- Yes
- No
If yes, please explain.
Do you have academic honors, extracurricular activities held, etc.?
- Yes
- No
If yes, please explain.
Knowledge, Skills, & Abilities
Computer Skills: Proficient in Microsoft Office
- Word
- Excel
- PowerPoint
- Outlook
- Access
Please check all that apply.
Licenses or Certifications
Valid Driver's License Number:
Expiration (Mo/Yr)
Professional License/Certificate
Expiration (Mo/Yr)
Professional License/Certificate
Expiration (Mo/Yr)
Professional License/Certificate
Expiration (Mo/Yr)
Employment - Begin with present or most recent employer
Company
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Employed From
Date Format: MM slash DD slash YYYY
Employed To
Date Format: MM slash DD slash YYYY
Reason for Leaving (Mandatory Answer)*
May we contact your previous supervisor for a reference?
- Yes
- No
Company
Company Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Employed From
Date Format: MM slash DD slash YYYY
Employed To
Date Format: MM slash DD slash YYYY
Reason for Leaving (Mandatory Answer)
May we contact your previous supervisor for a reference?
- Yes
- No
Company
Company Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Employed From
Date Format: MM slash DD slash YYYY
Employed To
Date Format: MM slash DD slash YYYY
Reason for Leaving (Mandatory Answer)
May we contact your previous supervisor for a reference?
- Yes
- No
Company
Company Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Employed From
Date Format: MM slash DD slash YYYY
Employed To
Date Format: MM slash DD slash YYYY
Reason for Leaving (Mandatory Answer)
May we contact your previous supervisor for a reference?
- Yes
- No
Company
Company Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Employed From
Date Format: MM slash DD slash YYYY
Employed To
Date Format: MM slash DD slash YYYY
Reason for Leaving (Mandatory Answer)
May we contact your previous supervisor for a reference?
- Yes
- No
Company
Company Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Supervisor
Job Title
Starting Salary
Ending Salary
Responsibilities
Employed From
Date Format: MM slash DD slash YYYY
Employed To
Date Format: MM slash DD slash YYYY
Reason for Leaving (Mandatory Answer)
May we contact your previous supervisor for a reference?
- Yes
- No
Work Reference - List three (3) *professional* references
Must be professional/supervisor/instructor
Name
First Last
Occupation
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Name
First Last
Occupation
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Name
First Last
Occupation
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Source
Please indicate how you heard about this job:
Disclaimer & Signature
I understand that failure to reveal any prior employer, or giving false or misleading information by me on any part of this application for employment is grounds for termination from the company or its' subsidiaries. I understand that if I am hired, my employment is for no definite time and may be terminated at any time without prior notice. I authorize the agency to obtain a 7 year Motor Vehicle Report. I understand the results of the report may determine the continuation of the application process. *Applicants will receive consideration of positions without regard to race, color, religion, age, sex, sexual orientation, martial status or individuals with disabilities.
I understand the above disclaimer*
- Yes
Date*
Date Format: MM slash DD slash YYYY
Equal Employment Opportunity Information
The information you give in this section is optional. It is used by the agency to comply with Federal guidelines by monitoring their equal employment effort.
Ethnic Background (OPTIONAL):
Gender:
- Female
- Male
Date of Birth
Date Format: MM slash DD slash YYYY
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Employment Application

Applicant Information

Education

Knowledge, Skills, & Abilities

Licenses or Certifications

Employment - Begin with present or most recent employer

Work Reference - List three (3) *professional* references

Source

Disclaimer & Signature

Equal Employment Opportunity Information

Work Reference - List three (3) professional references