Employment Application

The Drug Abuse Treatment Association, Inc., (DATA) is an equal opportunity employer and adheres to the principles and practices outlined in the Civil Rights Act of 1964, which prohibits discrimination in employment on the basis of race, sex, religion or national origin and Public Law 90-202 which prohibits discrimination based on age. We appreciate your interest in our company and assure you that we are interested in your qualifications. An understanding of your background and work history will aid us in placing you in a position that meets your qualifications and may possibly assist us in your future advancement with DATA. This application will be given every consideration, but its receipt does not imply that the applicant will be employed. Each question should be answered in a complete and accurate manner as no action can be taken on this application until all questions have been answered.

Applicant Name*
First Middle Initial Last
Date of Submission*
Desired Position*
Desired Start Date*
Desired Employment Status*
- Full Time
- Part Time
- Temporary
Resume
Please upload your resume
.pdf, .doc, .docx
Accepted file types: pdf, doc, docx, Max. file size: 5 MB.
Prospective employees will receive consideration without discrimination of race, color, religion, sex, sexual orientation, natural origin, age, veteran status, pregnancy or qualified individuals with disabilities.
Personal Information
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email Address*
Enter Email Confirm Email
Are you 21 or over?*
- Yes
- No
If you worked in any of your previous positions under another name, please give that name(s):
Citizenship Status
Are you a United States Citizen?*
- Yes
- No
If no, can you provide documents of employment eligibility?
- Yes
- No
Type/Document
Criminal History
A conviction record may not necessarily bar you from employment. Facts such as how recent and the type of crime will be considered.
Have you ever been convicted of a crime (including DUI or any minor traffic offenses)?*
- Yes
- No
Dates and explanations of offense(s)
Date Explanation
Substance Use History
Have you ever received treatment for alcohol or drug use?*
- Yes
- No
Is yes, how long ago?
Where did you receive treatment?
Have you used any illegal drugs in the last 12 months?*
- Yes
- No
Are you willing to take a drug screen at your own expense?*
- Yes
- No
Do you smoke cigarettes or use tobacco products, including vaporizers or e-cigarettes?*
- Yes
- No
Motor Vehicle History
Do you have a valid Driver’s License?*
- Yes
- No
State issued:
Number of years licensed:
Driver’s License number:
Expiration:
Month
Day
Year
Have you had any motor vehicle accidents or violations in the past three (3) years?*
- Yes
- No
Dates and explanations of accident(s) or violation(s):
Date Explanation
Employment Desired
Are you seeking:*
- Full-time
- Part-time
- On-call
- Temporary
- Other
Please describe:
Desired position:*
Desired salary*
Do you have a professional license (i.e., LMFT, LMHC, etc.)?*
- Yes
- No
If yes, what?
Are you requesting supervision for professional licensure?*
- Yes
- No
Are there any days/hours you will be unable or unwilling to work?*
- Yes
- No
If yes, please specify when:
Have you ever applied to DATA?*
- Yes
- No
When and what position:
Have you ever worked at DATA?*
- Yes
- No
When and what position:
How were you referred to DATA?*
- Online job posting
- Friend
- Newspaper advertisement
- DATA employee
- Job fair
- College/University job board
- Other
What site?
Who?
Please describe:
Are you currently employed?*
- Yes
- No
If hired, do you expect to be engaged in any other type of employment?*
- Yes
- No
Where and how many hours per week?
Employment History
Please complete the following section, starting with your current or most recent employment position.
Company name (Present or most current)*
Position*
Company address*
Street Address Address Line 2 City State ZIP Code
Name of supervisor
Phone
Dates of employment
Start date
End date
End date
Salary
Duties or responsibilities
Reason for leaving
Did you have another job before this one?*
- Yes
- No
Company name (Second most recent)*
Position*
Company address*
Street Address Address Line 2 City State ZIP Code
Name of supervisor
Phone
Dates of employment
Start date
End date
End date
Salary
Duties or responsibilities
Reason for leaving
Would you like to list another previous job?*
- Yes
- No
Company name (Third most recent)*
Position*
Company address*
Street Address Address Line 2 City State ZIP Code
Name of supervisor
Phone
Dates of employment
Start date
End date
End date
Salary
Duties or responsibilities
Reason for leaving
Would you like to list another previous job?*
- Yes
- No
Company name (Fourth most recent)*
Position*
Company address*
Street Address Address Line 2 City State ZIP Code
Name of supervisor
Phone
Dates of employment
Start date
End date
End date
Salary
Duties or responsibilities
Reason for leaving
We may contact the employers listed above unless you indicate those that you do not want us to contact.
Do you have any employers that we may not contact?*
- Yes
- No
Employer(s) and explanation(s)
Employer Explanation
Military Service
Did you serve in the United States Armed Forces or Coast Guard?*
- Yes
- No
What branch?
Describe any training you received that may be relevant to the position for which you are applying
Education
Graduate school
Graduate name/location Course of study Number of years completed
Did you graduate?
- Yes
- No
Type of degree
- MA
- MS
- PhD
- PsyD
College
College name/location Course of study Number of years completed
Did you graduate?
- Yes
- No
Type of degree
- AA
- BS
- BA
Business/Trade school
Business/trade name/location Course of study Number of years completed
Did you graduate?
- Yes
- No
Type of degree
High school
High school name/location Special coursework Number of years completed
Did you graduate?
- Yes
- No
Type of degree
- Diploma
- GED
If you did not graduate, why did you leave HS?
Are you planning to pursue further studies?*
- Yes
- No
If so, when, where, and what courses?
List any scholastic honors, offices held, or activities involved during high school and/or college
List and describe any other school, certifications, or specialized trainings
Skills and Abilities
Do you type?*
- Yes
- No
Speed/Accuracy
- Excellent
- Good
- Average
- Needs practice
Do you have any specialized computer training?*
- Yes
- No
If yes, what?
Computer Proficiency
- MS Word
- MS Excel
- MS Powerpoint
- MS Access
- MS Outlook
- Adobe Reader/Writer
- Other
Please list
List any other skills or abilities that you feel would be relevant to your employment with DATA
Language Proficiency
English
- Read
- Write
- Understand
Spanish
- Read
- Write
- Understand
Creole
- Read
- Write
- Understand
Other
- Read
- Write
- Understand
Do you have any physical conditions which might limit your ability to perform the job for which you are applying?*
- Yes
- No
Please describe this condition and how you can perform the job in spite of it
Have you ever received Worker’s Compensation or Disability Income payments?*
- Yes
- No
Please provide details of the injury and Employer when injured
Will you abide by all DATA’s safety rules, including all policies and procedures?*
- Yes
- No
References
Click on the + sign to add more references.
Name Phone number E-mail address Relationship Address

Click on the + sign to add more references.
Narrative
Use the space below to describe why you are interested in working for DATA and to list those skills which you feel particularly qualify you for a position with us.*
Affidavit
I certify that the answers given by me to the foregoing questions and statements are true and correct without any consequential omissions of any kind whatsoever. I understand that any misleading or incorrect statements may render this application void, and, if employed, would be cause for my termination. I further agree that the company shall not be liable in any respect if my employment is terminated because of falsify of statements, answers or omissions made by me in this questionnaire. I also authorize the companies, schools or persons named above to give any information regarding my employment, character or qualifications and hereby release said companies, schools or persons from all liability for any damage for issuing this information. I certify that all statements and answers to questions about my health are true and were made without reservations and agree to expressly waive all provisions of law prohibiting my physician, person, hospital or other institution from disclosing to the company any information regarding treatment rendered now and in the future. I further understand that the taking of drug tests are a condition of employment and refusal to take such tests when asked will subject me to termination. I also understand that no person is authorized to enter into any written or verbal employment contracts on behalf of the company without the express written consent of the President.
*
- I consent
- I do not consent
Please type your name if you consent*
Please type your name if you DO NOT consent*

10876

DATA IS A DRUG-FREE WORKPLACE WE CONDUCT DRUG SCREENS ON ALL POTENTIAL EMPLOYMENT APPLICANTS EMPLOYMENT IS CONDITIONAL PENDING THE OUTCOME OF THE SCREENING RESULTS PLEASE DO NOT APPLY FOR EMPLOYMENT IF YOU ARE UNABLE TO PASS A DRUG SCREEN

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