*fields are mandatory

Behavioral Health Solutions of South Texas
Application for Employment

Print or type. Fill out the application form completely; sign and return the application. We are an equal opportunity employer and do not unlawfully discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Equal access to employment, services, and programs is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of Behavioral Health Solutions of South Texas (BHSST).

Applicant name* : Date :
Position(s) Applying For* : Salary Desired :
Address* : City* :
Telephone # : Social Security # :
Type of employment desired* : full-time   part-time   temporary
Date you will be available to start work* :
Do you have any objection to working overtime if necessary?* Yes   No
Can you travel if required by this position?* Yes   No
Have you ever been previously employed by our organization?* Yes   No
Can you submit proof of legal employment authorization and identity?* Yes   No
Have you ever had a license and/or employment suspended and/or terminated?* Yes   No
Have you ever been charged, convicted, or pleaded “no contest” to a crime?* Yes   No
If yes, please explain (a conviction will not automatically bar employment)
Drivers license number (if driving is an essential job duty)
How were you referred to us?

Employment History : Include all information from your past four employers starting with the most recent.

Employer : Position held :
Address : Telephone # :
Immediate supervisor and title :
Dates employed :
from to
Salary :
Job summary :
Reason for leaving :
 
Employer : Position held :
Address : Telephone # :
Immediate supervisor and title :
Dates employed :
from to
Salary :
Job summary :
Reason for leaving :
 
Employer : Position held :
Address : Telephone # :
Immediate supervisor and title :
Dates employed :
from to
Salary :
Job summary :
Reason for leaving :

Employment History continued :

Employer : Position held :
Address : Telephone # :
Immediate supervisor and title :
Dates employed :
from to
Salary :
Job summary :
Reason for leaving :
 

Other Skills and Qualifications

Summarize any job-related training, skills, licenses, certificates, and/or other qualifications :
 

Educational History
List school name and location, years completed, course of study, and any degrees earned :

High school* :
College* (transcript must be included) :
Technical Training :
Other :
 

References

List 3 references names, telephone numbers, and years known (do not include relatives):
 

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY AND INDICATE YOUR UNDERSTANDING AND ACCEPTANCE BY SIGNING IN THE SPACE PROVIDED.

I hereby authorize Behavioral Health Solutions of South Texas to contact, obtain, and verify the accuracy of information contained in this application from all previous employers, educational institutions, criminal justice agencies, and references. This information may include, but is not limited to, academic, achievement, performance, attendance, personal history, criminal history check, licenses and driving records. I also hereby release from liability Behavioral Health Solutions of South Texas and its representatives for seeking, gathering, and using such information to make employment decisions and all other persons or organizations for providing such information.

I understand that any misrepresentation or material omission made by me on this application will be sufficient cause for cancellation of this application or immediate termination of employment if I am employed, whenever it may be discovered.

I understand that it is the policy of Behavioral Health Solutions of South Texas to provide a drug-free, healthful, and safe workplace. To help ensure a safe and healthful working environment, applicants shall be required to undergo urine testing prior to employment. Any applicant who has a positive confirmatory test result for drugs or refuses to submit to a drug screen will be disqualified from further consideration for employment.

If I am employed, I acknowledge that there is no specified length of employment and that this application does not constitute an agreement or contract for employment. Accordingly, either I or Behavioral Health Solutions of South Texas can terminate the relationship at will, with or without cause, at any time, so long as there is no violation of applicable federal or state law.

I understand that it is the policy of Behavioral Health Solutions of South Texas not to refuse to hire or otherwise discriminate against a qualified individual with a disability because of that persons need for a reasonable accommodation as required by the ADA.

I also understand that if I am employed, I will be required to provide satisfactory proof of identity and legal work authorization within three days of being hired. Failure to submit such proof within the required time shall result in immediate termination of employment.

I represent and warrant that I have read and fully understand the foregoing, and that I seek employment under these conditions.

Applicant signature :
Date :
 

CONSENT FOR DRUG TESTING

This is to certify that I consent and authorize BHS of SOUTH TEXAS to perform drug testing as a requirement for my employment.

I also authorize the release of the test results from Redwood Toxicology Laboratory to appropriate BHS of SOUTH TEXAS if I file a grievance regarding this matter or to appropriate agencies pursuant to State of Federal Law.

I authorize the Director of Operations for BHS of South Texas to receive testing results and/or progress reports. These reports shall be maintained in the Director of Operation’s office.

I authorize BHS of SOUTH TEXAS to contact my physician(s) to confirm medical Prescriptions, if necessary.

I UNDERSTAND THAT I DO NOT HAVE TO PROVIDE A URINE SPECIMEN IF I CHOOSE NOT TO DO SO, BUT THAT MY REFUSAL WILL RESULT IN MY IMMEDIATE TERMINATION OR NOT BEING CONSIDERED FOR EMPLOYMENT.

I am advised that if the test results are positive, I may request to have an independent drug test performed at my own expense, on my urine specimen that yielded the positive test result. I may be subject to disciplinary action, including IMMEDIATE TERMINATION if the test results were positive. I understand that as an applicant, confirmed positive test will make me ineligible for hire with BHS of South Texas for two years. I understand that the BHS of South Texas shall notify me of the test results.

I have received a copy of the BHS of South Texas’s Drug and Alcohol Use and Drug Testing policy. I have read and understand the provisions of such policy and agree to abide by the provisions set forth. I further understand that the policy is part of the rules and regulations governing my employment with the BHS of South Texas.

I hereby release the BHS of South Texas from any and all claims or liability arising out of or relating to the enforcement of its policy, specifically including, but not limited to, all claims for injuries to my person, damage to my reputation resulting from drug and alcohol testing or the release of information concerning such testing.

I consent to provide a urine specimen.

I refuse to provide a urine specimen.

EMPLOYEE/APPLICANT :
Signature :
Print Name :
Employee Number :
Date :
WITNESS :
Signature :
Print Name :
Position :
Date :
 

Behavioral Health Solutions of South Texas
5510 N. Cage Blvd., Suite C
Pharr, TX 78577
Office (956) 787-7111/Fax (956) 781-2233

BACKGROUND CHECK AUTHORIZATION AND RELEASE FORM

I hereby authorize any investigator or duly accredited representative of Behavioral Health Solutions of South Texas (BHSST) bearing this release to obtain any information from schools, employers, criminal justice agencies, or individuals, relating to my activities. This information may include, but is not limited to, academic, achievement, performance, attendance, personal history, disciplinary, arrest, and conviction records. It is expressly understood that any information given is to be used for the purpose of determining my acceptability for employment.

I hereby release any individual, including record custodians, from any and all liability for damages or claims of whatever kind or nature, which may at any time result to me on account of compliance, or any attempts to comply, with this authorization.

I also understand that an offer of employment with Behavioral Health Solutions of South Texas will depend on the outcome of the criminal history record information. I further understand that if the results indicate that I was convicted of a felony or had an offense involving moral turpitude (including, but not limited to theft, rape, murder, swindling, and indecency with a minor) that I never disclosed, will make me ineligible for hire with Behavioral Health Solutions of South Texas.

Applicant Signature :
Date :
 

The information requested below is necessary to obtain accurate criminal history record information. Please print or type.

Legal Name* :
Last*

First*

Middle
Driver’s License# : State* :
DOB :