Online Employment Application

Please fill out form completely. Fields marked with * are Required.


(  - 
*     *
*
* * *


Please list appropriate information about the position(s) for which you wish to apply.

     (mm/dd/yyyy)

           (mm/dd/yyyy)

Indicate work preferences (check all that apply)




*
  





Have you previously been employed by Hamilton Center, Inc.?
(mm/dd/yyyy)

* Do you have a valid Drivers License?
* Have you ever been convicted of an offense other than a minor traffic violation that has NOT been sealed or expunged as allowed by law?
(mm/dd/yyyy)


* Do you have a legal right to work in this country?
(mm/dd/yyyy)




Clerical Skills (Check those that apply) (Speed







EDUCATION

High School: *

* Did you graduate or obtain a GED?



Vocational/Trade School:

Did you graduate?
Date:    /  (mm/yyyy)


College/University:

Did you graduate?
Date    /  (mm/yyyy)


Graduate School:

Did you graduate?
Date    /  (mm/yyyy)


* Are you a veteran?


EMPLOYMENT HISTORY

Begin with current or most recent position first.

Employer 1


(  - 

(mm/dd/yyyy)


Status


(mm/dd/yyyy)



Employer 2


(  - 

(mm/dd/yyyy)


Status


(mm/dd/yyyy)



Employer 3


(  - 

(mm/dd/yyyy)


Status


(mm/dd/yyyy)



Licensed Professionals Only

Residency/Internship/Fellowship/Post Doctoral Training:


(mm/dd/yyyy) (mm/dd/yyyy)


(  - 

Residency/Internship/Fellowship/Post Doctoral Training:


(mm/dd/yyyy) (mm/dd/yyyy)


(  - 

Licensure/Registrations/Certifications/Teaching Endorsements, etc.
(mm/dd/yyyy)

(mm/dd/yyyy)
(mm/dd/yyyy)

If applying for a Clinical Therapist position but not currently licensed, please answer the following questions:

a. Are you eligible for Indiana licensure as a Clinical Therapist or Social Worker?

b. If so, what licensure are you eligible for? (select one)

c. When do you anticipate taking your licensure exam?

d. Will you need to complete any additional coursework before taking the licensure exam?


REFERENCES

Reference 1



(  - 
(  - 

Reference 2



(  - 
(  - 

Reference 3



(  - 
(  - 

Applicant's Certification and Agreement

     I certify that these facts are true and complete to the best of my knowledge. I understand that if I am employed, false statements on this application shall be considered sufficient cause for dismissal.

     I understand that if I am hired, the length of my employment is not guaranteed. Recognizing that I will be free to voluntarily terminate my employment at any time, with or without cause, I acknowledge that the Center will be free to terminate my employment at any time, with or without cause.

     I agree to verify my highest education completed by providing a copy of my High School or College diploma, if hired. I also agree to request an official transcript of my highest degree be sent directly to Hamilton Center Inc.'s Human Resources Department from my college/university if I am offered a bachelor or above position. I understand that my continued employment is contingent upon receipt of these documents.

     I understand that Hamilton Center, Inc. does not discriminate in its employment practices against any person because of race, color, national or ethnic origin, gender, age or disability.

     I acknowledge notification that Hamilton Center, Inc. participates in the U.S. Citizenship and Immigration Services (USCIS) E-Verify program to confirm employment eligibility and social security number validity for new hires. In the event I am offered a position at Hamilton Center, Inc., I understand that I will be required to comply with a post-offer, pre-employment drug screen and TB test.

  


Background Authorization Release Form

     I hereby authorize Hamilton Center, Inc. to conduct a Child Protective Services and Indiana Department of Child Services criminal fingerprinting background check at the time of hire and every four years (or at contract renewal when applicable) for any employee that has direct contact on a regular and continuing basis with DCS and IVB clients. A qualified confirmation must be received to continue employment.

     I hereby authorize Hamilton Center, their Consumer Reporting Agency (CRA), and their designated agents and representatives to conduct a review of my background causing a consumer report and/or an investigative consumer report to be generated for employment purposes and for future preparation of a consumer report or investigative consumer report for purposes of retention, promotion or reassignment unless revoked in writing. I understand that the scope of the consumer report and/or investigative consumer report may include, but is not limited to, the following areas: verification of social security number, current and previous residences, employment history including all personnel files, education history including transcripts, character references, credit history and reports, criminal history records from any criminal justice agency in any or all federal, state, county, city jurisdictions, motor vehicle records to include traffic citations and registration, any other public records, or information relative to my character, general reputation, personal characteristics or mode of living, if applicable. I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, the Consumer Reporting Agency (CRA) or its' agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. This authorization also releases from liability to extent permitted by law or responsibility all persons, companies, or corporations supplying information regarding my background to Hamilton Center, Inc. providing they observe certain conditions of good faith and reasonableness in reporting their observations and knowledge of my clinical ability, ethical character, ability to work cooperatively with others, and other information relevant to consideration of my qualifications for employment. If an investigative consumer report is conducted I understand that I have the right to request additional information about the nature of the report and a copy of the report by calling the Consumer Reporting Agency (CRA).

     California, Minnesota & Oklahoma Applicants Only: Please initial here to have a copy of your consumer report sent directly to you. Minnesota and Oklahoma applicants will receive a copy directly from the Consumer Reporting Agency (CRA).

     California Applicants: Under Section 1786.22 of the California Civil Code, you have the right to request from the Consumer Reporting Agency (CRA), upon proper identification, the nature and substance of all information in its files on you, including the sources of information, and the recipients of any reports on you, which the Consumer Reporting Agency (CRA) has previously furnished within the two-year period preceding your request. You may view the file maintained on you by the Consumer Reporting Agency (CRA) during normal business hours. You may also obtain a copy of this file upon submitting proper identification and paying the costs of duplication services. Upon making a written request, you may receive a summary of your report via telephone.

     Maine Applicants: Under Chapter 210 Section 1314 of Maine Revised Statutes, you have the right, upon request, to be informed within 5 business days of such request of whether or not an investigative consumer report was requested. If such report was obtained, you may contact the the Consumer Reporting Agency (CRA) and request a copy.

     New York Applicants: Under Article 25 Section 380-c (b) (2) of the New York General Business Law, you have the right, upon written request, to be informed of whether or not an investigative consumer report was requested. Under Article 25 Section 380-g of the New York General Business Law, should a consumer report received by an employer contain criminal conviction information, the employer must provide to the applicant or employee who is the subject of the report, a printed or electronic copy of Article 23-A of the New York Correction Law, which governs the employment of persons previously convicted of one or more criminal offenses. Please initial here to acknowledge receipt of Article 23-A of the New York Correction Law.

  

Voluntary Request for Information

The following voluntary information is used to conduct background investigations prior to a hire offer. This information will not be maintained with your application nor will it be used in making the hiring decision.

(mm/dd/yyyy)