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Employment Application

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, sexual orientation, gender, 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
 

First Name
Middle Name
Last Name
Address Line 1
City
State
Zip
Please enter a number where you can be reached between 8:00am-5:00pm. Please include area code (10 digit number).
Please include the specific Job numbers you are applying for. Submissions with general responses or "any" will not be considered.

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

Did You Graduate?

Additional School

Did you Graduate

Additional School

Did You Graduate?

Licensures and Certifications

Do You Have a Clinical License or Certification
If you answer yes Type and Number is required.
Counseling Applicants, are you license eligible with the Georgia Composite Board of Professional Counselors, Social Workers, Marriage & Family Therapists?
Did you complete a clinical internship?

Availability

Do you have a legal right to remain and work permanently in the United States? (Proof of right to work will be required.)
Are you available for full time or part time work?
ex. 9 AM-5 PM
Will you work overtime is asked?
Would you be willing to relocate?
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 and work in a position that transports or operates an agency vehicle

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

Address Line 1
City
State
Zip
mm/yy Ex. 3/19-5/20
State reason an explain length on inactivity between employers
Can we contact employer?
Address Line 1
City
State
Zip
mm/yy Ex. 3/19-5/20
State reason an explain length on inactivity between employers
Can we contact employer?
Address Line 1
City
State
Zip
mm/yy Ex. 3/19-5/20

Additional Employer

State reason and explain any length of inactivity between employers
Can we contact employer?
Address Line 1
City
State
Zip
mm/yy Ex. 3/19-5/20
State reason an explain length on inactivity between employers
Can we contact employer?

Additional Employer

Address Line 1
City
State
Zip
mm/yy Ex. 3/19-5/20
State reason an explain length on inactivity between employers
Can we contact employer?
Were you ever terminated?
Were you ever subject to disciplinary action?
Were you ever promoted or the recipient of a commendation?

Military Experience

Were you in the U.S. Armed Forces?
Start Date
End Date

Professional References

Were you supervised by this person?
Were you supervised by this person?
Were you supervised by this person?
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.