Employment Application Healthy Healing Counseling, Inc. 166 Old Waterville Road, Suite #1 Oakland, Maine 04963 (207) 465-9001 Applicant Information Last Name Invalid Input First Name Invalid Input M.I. Invalid Input Street Address Invalid Input Apartment/Unit # Invalid Input City Invalid Input State Invalid Input Zip Code Invalid Input Phone Invalid Input Email Invalid Input Date Available Invalid Input Social Security Number Invalid Input Desired Salary Invalid Input Position Applied For Invalid Input Are you a citizen of the United States? Yes No Invalid Input If no, are you authorized to work in the U.S.? Yes No Invalid Input Have you ever worked for this company? Yes No Invalid Input If yes, when? Invalid Input Have you ever been convicted of a felony? Yes No Invalid Input If yes, explain Invalid Input Education High School Invalid Input Address Invalid Input From Invalid Input To Invalid Input Did you Graduate? Yes No Invalid Input Diploma Invalid Input College Invalid Input Address Invalid Input From Invalid Input To Invalid Input Did you Graduate? Yes No Invalid Input Degree Invalid Input Other Invalid Input Address Invalid Input From Invalid Input To Invalid Input Did you Graduate? Yes No Invalid Input Diploma Invalid Input References Please list three professional references. Full Name Invalid Input Relationship Invalid Input Company Invalid Input Phone Invalid Input Address Invalid Input Full Name Invalid Input Relationship Invalid Input Company Invalid Input Phone Invalid Input Address Invalid Input Full Name Invalid Input Relationship Invalid Input Company Invalid Input Phone Invalid Input Address Invalid Input Previous Employment Company Invalid Input Phone Invalid Input Address Invalid Input Supervisor Invalid Input Job Title Invalid Input Starting Salary Invalid Input Ending Salary Invalid Input Responsibilities Invalid Input From Invalid Input To Invalid Input Reason for Leaving Invalid Input May we contact your previous supervisor for a reference? Yes No Invalid Input Company Invalid Input Phone Invalid Input Address Invalid Input Supervisor Invalid Input Job Title Invalid Input Starting Salary Invalid Input Ending Salary Invalid Input Responsibilities Invalid Input From Invalid Input To Invalid Input Reason for Leaving Invalid Input May we contact your previous supervisor for a reference? Yes No Invalid Input Company Invalid Input Phone Invalid Input Address Invalid Input Supervisor Invalid Input Job Title Invalid Input Starting Salary Invalid Input Ending Salary Invalid Input Responsibilities Invalid Input From Invalid Input To Invalid Input Reason for Leaving Invalid Input May we contact your previous supervisor for a reference? Yes No Invalid Input Military Service Branch Invalid Input From Invalid Input To Invalid Input Rank at Discharge Invalid Input Type of Discharge Invalid Input If other than honorable, please explain Invalid Input Disclaimer and Signature By submitting this form I certify that my answers are true and complete to the best of my knowledge. If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release. I understand that if I am interviewed, I will be required to sign and date this application. Signature: ______________________________________________ Date: ________________________ Please verify you are human(*) Invalid Input Submit