Apply to Portage Path Behavioral Health "*" indicates required fields Step 1 of 9 11% Application for EmploymentPosition*What open position are you applying for?Date of Application MM slash DD slash YYYY How did you learn about us?Social MediaCompany WebsiteJob Board (Indeed, Zip Recruiter, Etc.)AdvertisementEmployment AgencyRelative/FriendOtherIf Other, please describe:Name First Middle Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Best time to contact you:MorningLunchtimeEveningPhone*Email* Enter Email Confirm Email If you are under 18 years of age, can you provide required proof of your eligibility to work? Yes No Have you ever filed an application with us before? Yes No Date of Prior Application MM slash DD slash YYYY Have you ever been employed with us before? Yes No Date of Prior Employment MM slash DD slash YYYY Do any of your friends or relatives, other than spouse, work here? Yes No Were you referred to this position by a current PPBH employee? Yes No If yes, please list current employee nameAre you currently employed? Yes No May we contact your present employer? Yes No Are you prevented from lawfully becoming employed in this country because of Visa or Immigration Status? Yes No Proof of citizenship or immigration status will be required upon employment.Date Available for Work MM slash DD slash YYYY What is your desired salary range?Are you available to work: Full Time Part Time Temporary Please describe your availabilityIf Full Time: 1st, 2nd, or 3rd shift availability? If Part Time: Mornings, Afternoons, Evenings? If Temporary: Please indicate the date range you are available.Are you currently on "lay-off" status and subject to recall? Yes No Can you travel if a position requires it? Yes No EducationHigh School EducationHigh School Attended (List Name and Address)Did you earn your high school diploma?Undergraduate EducationUndergraduate College Attended (List Name and Address)Undergraduate Course(s) of StudyNumber of Years of Undergraduate CompletedUndergraduate Degree(s) EarnedGraduate EducationGraduate College Attended (List Name and Address)Graduate Course(s) of StudyNumber of Years of Graduate CompletedGraduate Degree(s) EarnedPost-Graduate EducationPost-Graduate College Attended (List Name and Address)Post-Graduate Course(s) of StudyNumber of Years of Post-Graduate CompletedPost-Graduate Degree(s) EarnedAdditional Educational ExperienceDescribe any specialized training, apprenticeship, skills and extra-curricular activities.Describe any job-related training received in the United States military. Employment ExperienceStart with your present or most recent job. Include any job-related military service assignments and volunteer activities. You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities or other protected status. If you have additional employment experience you wish to share with us, please include those positions and information in a separate document. You may upload the document at the end of this application.Employment 1EmployerEmployer AddressEmployer PhoneEmployed Start Date MM slash DD slash YYYY Employment End Date MM slash DD slash YYYY Job TitleSupervisorReason for LeavingWork PerformedEmployment 2EmployerEmployer AddressEmployer PhoneEmployed Start Date MM slash DD slash YYYY Employment End Date MM slash DD slash YYYY Job TitleSupervisorReason for LeavingWork PerformedEmployment 3EmployerEmployer AddressEmployer PhoneEmployed Start Date MM slash DD slash YYYY Employment End Date MM slash DD slash YYYY Job TitleSupervisorReason for LeavingWork PerformedEmployment 4EmployerEmployer AddressEmployer PhoneEmployed Start Date MM slash DD slash YYYY Employment End Date MM slash DD slash YYYY Job TitleSupervisorReason for LeavingWork Performed Additional Work Experience, Qualifications & SkillsList professional, trade, business or civic activities and offices heldYou may exclude membership which would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.Other QualificationsSummarize special job-related skills and qualifications acquired from employment or other experience.Specialized SkillsShare any specialized skills you may have (i.e. Abilities in computer use, software experience, typing Words Per Minute, etc) -- State any additional information you feel may be helpful to us in considering your application.Can you perform the essential functions of the job, for which you are applying, either with or without a reasonable accommodation? Yes No Note: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING. Portage Path Behavioral Health - For Applicants of Licensed/Certified PositionsThis section on needs to be filled out by those applying for a position which requires licensure or certification. If you are applying for a position that does not require licensure or certification you may skip this section. What license/certifications do you currently hold?Are you currently a resident in a Psychiatry Program? Yes No If yes, please give expected date of completion or date of graduation from the program.Are you now, or have you ever been, the subject of an investigation by any licensure certification board or other similar agency? Yes No If yes, describe the nature of each investigation, the agency involved, any case or file number and the outcome of each investigation.Have you ever been denied a license or certification or has any license or certification you held been suspended or revoked? Yes No If yes, provide the date(s) of each suspension or revocation, the reasons for suspension, revocation, any case or file numbers and the current status of the particular license or certificate. ReferencesThree pre-employment reference checks are required for employment at Portage Path Behavioral Health. Please complete the following to advise the Human Resource Department whom you have requested to complete your pre-employment reference checks to complete your application packet.Reference 1Reference 1 First Name Last Name PhoneEmail* AddressReference 2Reference 2 First Name Last Name PhoneEmail* AddressReference 3Reference 3 First Name Last Name PhoneEmail* AddressReference FormsPlease reach out to your references and let them know that they will be recieving a email when you submit your application from Portage Path Behavioral Health. If for some reason it does not appear in their inbox please have them check their junk mail or send them this link and have them complete their reference form. It is your responsibility to contact the references included in this application and request they fill out the form provided in the link and email.You Will Need to Contact Your References* I understand it is my responsibility to contact the references listed on this application and request they fill out the form that has been emailed to them. Application Waiver: AUTHORIZATION TO OBTAIN CONSUMER REPORT PURSUANT TO 15 U.S.C. §1681b(b)(2)(B)In connection with my application for employment (including contracts for services), I understand and authorize Portage Path Behavioral Health to obtain a background report for employment purposes. I understand that this inquiry may include, but is not limited to: criminal records, motor vehicle records, credit records, address verification, social security verification, civil court records, bankruptcy records, personal or professional references, education verification, and copies of prior personnel files. An inquiry may be made as part of a pre-employment screening process. I AUTHORIZE. WlTHOUt RESERVATION, ANY PART OR AGENCY CONTACTED ON BEHALF OF PORTAGE PATH BEHAVIORAL HEALTH TO FURNISH THE ABOVE-MENTIONED INFORMATION AND RELEASE THAT PARTY FROM ANY LIABILITY AND RESPONSIBILITY FOR DOING SO. A COPY OF THIS AUTHORIZATION SHALL HAVE THE SAME AUTHORITY AS THE ORIGINAL. I hereby release and discharge Portage Path Behavioral Health and their employees, agents successors and assigns, from any and all liability that may arise out of the investigation of my background as set forth herein. Use of date of birth is for identification purposes only and will be used only by the Consumer Reporting Agency to obtain background information about you. Consistent with its equal employment policies, Portage Path Behavioral Health will not consider this date of birth for the purposes of making any hiring decision. This authorization and disclosure is pursuant to the Fair Credit Reporting Act, 15 U.S.C. §I681 b(b)(2)(B).Today's Date* MM slash DD slash YYYY I attest that I have not been convicted of or pleaded guilty to a disqualifying offense.* I affirm that I will disclose to Portage Path Behavioral Health a conviction for any offense that has been sealed or expunged by a court of law, regardless of whether or not the conviction appears on a criminal background check. Please click link to review list of disqualifying offenses per ORC 5122-30-31 Rule 5122-30-31 - Ohio Administrative Code | Ohio LawsNotification Disclosure* I agree to notify Portage Path Behavioral Health within fourteen calendar days if, while employed by the residential facility, I am formally charged with, am convicted of, or plead guilty to a disqualifying offense. Failure to make notification to Portage Path Behavioral Health may result in termination of the applicant's employment.Name of Authorizing Consumer*Date of Birth* MM slash DD slash YYYY Driver's License*Social Security Number*Applicant Signature*Type your name SUBSTANCE ABUSE POLICY: APPLICANT ACKNOWLEDGEMENT, RELEASE AND CONSENTI agree that as a condition of applying for and, if offered, accepting employment at Portage Path Behavioral Health, I will be subject to the Company's policy regarding substance abuse. Specifically, as a condition for consideration of my application for employment, I agree to undergo testing for prohibited drugs and/or alcohol. I further understand and agree that if employed, as a condition of my employment, I will be required to submit to testing for drugs and/or alcohol under the following circumstances: I am discovered using, possessing or distributing prohibited drugs or alcohol in violation of the Company's Substance Abuse Testing or Drug-Free Workplace Policy. I am involved in an on-the-job accident that results in injury to me or any other individual which requires medical treatment, or which results in damage to Company property. I commit an unsafe act that endangers the lives or safety of other employees, clients or other individuals or endangers Company property. I understand that the purpose of the drug/alcohol testing is to determine or rule out the presence of prohibited substances in my body for performance and safety reasons. I understand that if employed, as a condition of employment, if I refuse to comply with the company substance abuse policy, I will face disciplinary action, up to and including termination. Prohibited drugs are defined to include: Controlled substances including, but not limited to: amphetamines, barbiturates, benzodiazepines, cannabinoids (marijuana), cocaine, phencyclidine (PCP), opiates; methaqualone. Prescription drugs which have not been specifically prescribed by a licensed physician, prescribed for the employee, or are not being used for or in the manner prescribed. Over-the-counter medications which are not being used for or in the manner recommended. I understand that once I am an employee of Portage Path Behavioral Health and should the results of the initial drug/alcohol screening be positive, I may request that confirmatory testing be done by the Company's designated laboratory at my expense. If the confirmatory test is negative, the Company will reimburse me for the cost of the confirmatory test. I understand that pursuant to Company policy, the Company may search me and my property if reasonable suspicion exists to believe that I have violated the Drug-Free Workplace or Substance Abuse Testing Policies. As a condition of employment, I consent to all such searches. I consent to and authorize Portage Path Behavioral Health and any physician, laboratory, hospital or medical professional retained by Portage Path Behavioral Health to both conduct such testing and to provide the results to Portage Path Behavioral Health. I release Portage Path Behavioral Health, their employees, agents, contractors and successors and assigns from any liability whatsoever arising from the request to undergo drug/alcohol testing, the testing procedures and any decisions made concerning continued employment based upon the results of the tests conducted.Applicant Signature*Type your nameDate* MM slash DD slash YYYY Resume, Cover Letter, and Additional Employment ExperiencePlease upload your resume and cover letter (and any additional Employment experience if applicable).Upload Resume*Max. file size: 50 MB.Upload Cover LetterMax. file size: 50 MB.Additional Employment ExperienceMax. file size: 50 MB.Applicant's StatementI certify that answers given herein are true and complete. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer. By typing my name on the Applicant Signature line below, I understand this electronic signature is the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement.Applicant's Signature*CAPTCHAConsent I agree to the privacy policy. Δ
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