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Pure Autism Counseling Center is an Equal Opportunity Educational Institution and EEO/Affirmative Action Employer committed to excellence through diversity. Employment offers are made on the basis of qualifications, and without regard to race, sex, religion, national or ethnic origin, disability, age, veteran status, or sexual orientation.

Complete the entire application. You may attach a resume, but you must still complete all questions, or your application will be deemed incomplete and may not be considered. Please fill out each box (don't just indicate "See Resume.") Applications with missing or invalid job numbers will not be considered for any position.

Position Applying For

Name (Last, First, Middle)

Other names under which you have attended school or been employed

Street Address

City

State

Zip

Social Security Number

Home Phone

Cell Phone

Other Phone

Are you eligible to work in the United States?

YesNo

Are you 18 years of age or older?

YesNo

what is your current age?

Are you currently employed?

YesNo

what is your current job title & dept?

Have you ever been employed by Pure Autism Counseling Center?

YesNo

Dates of employment & reason for leaving

Are you related to any current (company employee)?

YesNo

Their name & their relationship to you?

If required for position, do you have a valid driver’s license?

YesNo

State of issuance, license #, and expdate:

How did you learn about this employment opportunity at All Care One?

Education

Name Of Institute

Degree/Certificate Name

Date of Graduation if you graduate?

If No, # of years left to graduate

Degree received

City/State

Major

Other credentials/ licenses/ professional affiliations, etc., which are relevant to the job(s) for which you are applying.

Skills

Please list technical skills, clerical skills, trade skills, etc., relevant to this position. Include relevant computer systems and software packages of which you have a working knowledge, and note your level of proficiency (basic, intermediate, expert)

Work Experience

Please detail your entire work history. Begin with your current or most recent employer. If you held multiple positions with the same organization, detail each position separately. Attach additional sheets if necessary. Omission of prior employment may be considered falsification of information. Please explain any gaps in employment. Include full-time military or volunteer commitments. PLEASE DO NOT complete this information with the notation "See Resume," unless the position you are applying for is an executive level or medical provider position

PLEASE NOTE: Pure Autism Counseling Center reserves the right to contact all current and former employers for reference information.

Dates Employed (most recent position)

From

Job Detail

Full timePart Time

If part-time, # hrs./wk

Title

Starting Salary

Final Salary

Organization Name and Address

Supervisor’s Name, Title

Supervisor’s Phone #

Other Reference Name, Title

Other Reference Phone #

Contact my current references

At any timeOnly if I am a finalist candidate

Primary duties

Reason for Leaving

Attachment

Attach your ID / Drivers License

Attach resume

Attach degrees

PLEASE READ CAREFULLY AND SIGN THAT YOU UNDERSTAND AND ACCEPT THIS INFORMATION.

I certify that the information on this application and its supporting documents are accurate and complete. I understand and agree that failure to fully complete the form, or misrepresentation or omission of facts, represents grounds for elimination from consideration for employment, or termination after employment if discovered at a later date. I authorize Pure Autism CounselingCenterto to investigate, without liability, all statements contained in this application and supporting materials. I authorize references and former employers, without liability, to make full response to any inquiries in connection with this application for employment. If requested, I agree to submit to a physical exam, criminal and credit background investigation, and/or screening for illegal substances upon conditional offer of employment. I understand that this document is NOT an offer of employment and that an offer of employment if tendered, does NOT constitute a contract for continued guaranteed employment. I understand that staff employees of Pure Autism CounselingCenter serve AT-WILL, and the employment relationship may be terminated at any time by either party or any or no reason, other than a reason prohibited by law. If employed, I will be required to furnish proof of eligibility to work in the United States, to file a State security questionnaire and State loyalty oath, and to comply with the company and departmental regulations. I understand that if employed on a temporary basis, I would be paid for hours worked only, and would be ineligible for benefits including paid time off. If employed on a regular, benefits-eligible basis, I understand that I would be required to make mandatory contributions to the Pure Autism CounselingCenterRetirement System or to an optional retirement program, if applicable. I understand that any benefits I receive may be subject to change or is continuation at any time without prior notice. I understand that the first SIX MONTHS of regular employment represents a provisional period, during which I would not be eligible to apply for transfer or promotion and during which I may be terminated without the right of appeal.

Applicant Signature