To let Job Connection, Ltd. begin helping you connect to your new job ...

1. Complete the following application
2. Click on "Submit" to send
3. Send your resume as an e-mail attachment to jobconnection@verizon.net (MS Word preferred)
   OR
   Mail your resume to Job Connection, Ltd., PO Box 485, Bristol, RI 02809

Name (last, first, M.I.) (REQUIRED):

Mailing Address:

City or Town:

State:

Zip:
Work Phone (area code & ext.):

Cell Phone:

Home Phone (area code):

Voicemail:
 Yes          No

E-Mail Address (REQUIRED):

Position(s) Desired:
Degree:

Date Received:

License/Certificate:

Date Received:

Maiden Name (if used when degree, license, or certificate was awarded):

Minimum Annual Salary Required:

Benefits Required:

Full Time:

Part Time:

# of Hours:

FFS:

Will you work evenings? Yes   No

Weekends? Yes   No

On call? Yes   No

Geographic Area Desired:

Maximum Travel Time:


Will Relocate? Yes     No

Date You Can Begin:



Answer Yes or No if you would provide services to the following populations.
Indicate those with whom you have had experience.

Psychiatric, Acute:	Yes   No   Experience
DD, Mild/Moderate:	Yes   No   Experience
Sexual/Physical Abuse:	Yes   No   Experience
Physically Disabled:	Yes   No   Experience
Foster Care:	Yes   No   Experience
Adolescents:	Yes   No   Experience
Families:	Yes   No   Experience
Infant/Toddler:	Yes   No   Experience
Psychiatric, Chronic:	Yes   No   Experience
Autistic:	Yes   No   Experience
Elderly:	Yes   No   Experience
Substance Abuse:	Yes   No   Experience
Children:	Yes   No   Experience
Adults:	Yes   No   Experience
Crisis:	Yes   No   Experience
AIDS:	Yes   No   Experience

Answer Yes or No to the following work environments:

Hospital:	Yes     No
Vocational:	Yes     No
School:	Yes     No
Home-Based:	Yes     No
Day Treatment:	Yes     No
CMHC:	Yes     No
Residential:	Yes     No
Nursing Facility:	Yes     No
HMO:	Yes     No
Early Intervention:	Yes     No

List any foreign languages you speak fluently:


Supervisory Experience: Whom did you supervise? How many years?

Reason for leaving last or present position:

What are convenient times for you to interview?

How did you learn of Job Connection, Ltd.?

Have you ever applied for placement with us before? Yes     No

List three supervisors, past or present, who could be used as a reference:

Name:
Title:
Agency:
Work Phone (area code):
Home Phone (area code):
Name:
Title:
Agency:
Work Phone (area code):
Home Phone (area code):
Name:
Title:
Agency:
Work Phone (area code):
Home Phone (area code):

Have you ever been convicted of a felony?  Yes     No

If yes, please explain:


CHOOSE ONE:
 I will send my resume as a separate e-mail attachment to jobconnection@verizon.net (MS Word preferred).
 I will mail my resume to Job Connection, Ltd. at the address listed above.

By submitting this Application for Placement, I hereby declare that the information provided herein is true, correct, and complete to the best of my knowledge. I understand that any misstatement or omission of fact on this Application shall be considered cause for termination of the placement process.

I authorize investigation of all statements contained herein, on my resume, and the references listed above to give you any information concerning my previous employment and credentials.

I further understand that Job Connection, Ltd. is under no obligation to provide placement.