Employee Application Employee ApplicationPlease enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 5Personal Information Name *FirstLastAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutPhone Number *Email Employment Desired LayoutPosition Applying For: *Date Available *Are you employed?YesNoHave you ever been discharged or asked to resign from any previous employment?YesNoHave you ever applied to BHC before?YesNo Full TimePart TimeContractualSalary DesiredIf Yes, may we inquire of your present employer?YesNoIf yes, please explainIf yes, which position?How were you referred to us?Job PortalsAgencyJob FairWalk-InContacted by BHC HREmployee ReferralOtherBHC WebsiteNext Work Experience (List below the last four employers, starting with current employment first) Experience #1 LayoutEmployment start and end date Job TitleDutiesEmployer Address Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutSalaryReason for leaving Experience #2 LayoutEmployment start and end date Employment start and end date (copy)Job TitleDutiesEmployer Address Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutSalaryReason for leaving Experience #3 Layout Employment start and end date Employment start and end date Job TitleDutiesEmployer Address Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutSalaryReason for leavingPreviousNextVolunteer Work Experience #1 LayoutVolunteer start and end date Name of EmployerEmployer Address Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutRoleList of Duties Experience #2 Layout Volunteer start and end date Name of Employer Employer Address Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutRoleList of Duties Experience #3 Layout Volunteer start and end date Name of EmployerEmployer Address Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutRoleList DutiesPreviousNext MILITARY BACKGROUND (Leave blank if not applicable) Dropdown ItemsPlese SelectArmyAir ForceNavyMarinesLayoutAre you currently serving?YesNoAre you a combat veteran?YesNoIf yes,ReservesNational GuardType of discharge?EMPLOYMENT/PROFESSIONAL REFERENCES (Give the names below of three persons not related to you, whom you have a professional working relationship with and have known for at least one year) Reference #1 NameFirstLastAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayoutProfessional Relationship Years knownReference #2 NameFirstLastAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayout Professional Relationship Years knownReference #3 NameFirstLastAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeLayout Professional Relationship Years known PreviousNext Education Level of EducationGraduate SchoolCollegeTrade or Business SchoolHigh School Education #1 LayoutName of SchoolYears AttendedCourse of studyLocation of SchoolDid you graduate?YesNo Education #2 Layout Name of SchoolYears Attended Course of studyLocation of SchoolDid you graduate? YesNo Professional Information LayoutProfessional Licensure(s):Effective Date(s):Layout Certification(s):Effective Date(s):Out of State License(s): UNDER MARYLAND LAW AN EMPLOYER MAY NOT REQURE OR DEMAND ANY APPLICANT FOR EMPLOYMENT OR PROSPECTIVE EMPLOYMENT OR ANY EMPLOYEE TO SUBMIT TO TAKE A POLYGRAPH, LIE DETECTOR OR SIMILAR TEST OR EXAMINATION AS A CONDITION OF EMPLOYMENT. ANY EMPLOYER WHO VIOLATES THIS PROVISION IS GUILY OR A MISDEAMENOR AND SUBJECT TO A FINE NOT TO EXCEED $100.”AUTHORIZATION:“I CERTIFY THAT THE FACTS CONTAINED IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND UNDERSTAND THAT, IF EMPLOYED, FALSIFIED STATEMENTS ON APPLICATION SHALL BE GROUNDS FOR DISMISSAL. I AUTHORIZE INVESTIGATION OF ALL STATEMENTS CONTAINED HEREIN AND REFERENCES AND EMPLOYERS LISTED ABOVE TO GIVE YOU ANY AND ALL INFORMATION CONCERNING MY PREVIOUS EMPLOYMENT AND ANY PERTINENT INFORMATION THEY MAY HAVE, PERSONAL OR OTHERWISE, AND RELEASE BHC FROM ALL LIABILITY FOR ANY DAMAGE THAT MAY RESULT FROM UTILIZATION OF SUCH INFORMATION.”*REGULATIONS REQUIRE THAT YOU REPORT ANY AND ALL CRIMINAL HISTORY INCLUDING CONVICTIONS, PBJ, NOT CRIMINALLY RESPONSIBLE AND PENDING CHARGES. THE DETERMINATION OF EMPLOYMENT WILL BE MADE BASED ON YOUR QUALIFICATIONS AND PARTIALLY BASED ON ANY CRIMINAL HISTORY YOU MIGHT HAVE. HOWEVER, WE DO NOT RESTRICT EMPLOYMENT DUE TO A CRIMINAL HISTORY. A DECISION TO PROHIBIT EMPLOYMENT WILL BE BASED ON THE SEVERITY OF THE OFFENSE, HOW LONG AGO THE OFFENSE OCCURRED, AND ANY POSSIBLE IMPLICATIONS TO THE JOB FOR WHICH YOU ARE APPLYING. NONETHELESS, IF HIRED, FAILURE TO REPORT PAST OR FUTURE CRIMINAL ACTIVITY CAN RESULT IN TERMINATION OF YOUR EMPLOYMENT. IF HIRED, YOU WILL BE REQURED TO ALLOW US TO CHECK YOUR FEDERAL AND STATE CRIMINAL HISTORY.I ALSO UNDERSTAND AND AGREE THAT NO REPRESENTATIVE OF BHC HAS ANY AUTHORITY TO ENTER INTO ANY AGREEMENT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OF TIME, OR TO MAKE ANY AGREEMENT CONTRARY TO THE FORGOING, UNLESS IT IS IN WRITING AND SIGNED BY AN AUTHORIZED BHC REPRESENTATIVE.” LayoutSignature Clear Signature Date CRIMINAL BACKGROUND (You must report all criminal convictions, probation before judgement dispositions, not criminally responsible dispositions, and/or pending charges without a final disposition) Offense/Charge *Disposition *Date of Disposition *PreviousSubmit
