Employment Application

1 Tell us about yourself


This info will be transmitted securely.

2 What are you applying for?


3 Education


4 Licenses, Registrations, and Certifications


5 Work history

Include information for at least the last seven years, if applicable.


6 Personal information












7 References

Please provide three references.

Please include at least one professional reference.


8 Attach your resume

Only PDF or Word documents are accepted

By submitting this form, I am declaring myself aware that any omissions, falsifications, misstatements or misrepresentations above may disqualify me for employment consideration and, if I am hired, may be grounds for termination at a later date. I hereby grant LRCMHC permission to request schools, current or past employers, law enforcement agencies and other individuals and organizations to release information contained in their records for use in conducting research specifically relating to my suitability as an employee of LRCMHC, except where I have checked on this form that no inquiry be made. I understand this information is for use by LRCMHC and will be safeguarded against unauthorized disclosure to any agency or individual not having a legitimate need for it and the authority for its release. This consent shall continue to be effective during my employment if I am hired. I certify that to the best of my knowledge and belief all of the statements contained herein and on any attachments are true, correct, complete and made in good faith. In the event that I am employed, I understand that I am required to abide by the policies and procedures of LRCMHC. I also understand that any employment relationship with LRCMHC is of an “at will” nature, which means that the employee may resign at any time and the employer may discharge the employee at any time with or without cause. I understand that a physical examination and drug test will be required prior to employment and that a job offer is conditioned on the results of the test. I understand I may be asked to submit to periodic drug screens in the future. I also voluntarily agree to such tests.

© 2019 LRCMHC (1.0.1.6)