APPLICATION FOR EMPLOYMENT
Title of position for which you are applying: Substance Abuse Prevention Specialist
Colorado Association for School-Based Health Care
1801 Williams Street, Denver, CO 80218
E-MAIL: info@casbhc.org  FAX (303) 350-4296
RETURN TO
NOTICE
All areas of the application must be completed in full for consideration.
PERSONAL INFORMATION
Last Name
First Name
Home Address
MI
City
E-mail Address
State
Home Phone
Zip Code
Cell Phone
EDUCATION
List in chronological order starting with the most recent, all undergraduate schools, graduate schools, or other post-high
school educational programs attended or being attended:
School Name, City, State,
Dates of Attendance
Degree or Certificate
Conferred
Do you have current professional credential or license?
Date Conferred
Or Expected Degree and Date
Yes What? __________________________
No
1
WORK HISTORY
On the next four pages list your most recent employers. Begin with your current status. A resume will not be
accepted in lieu of the requested information.)
Job Title:
Full-time
Part Time
From (mo/yr)
Employer:
To (mo/yr)
Address:
Compensation
(per hour):
Immediate
Supervisor:
Reason for leaving:
Phone
Email
Address:
Duties:
2
Job Title:
Full-time
Part-time
From (mo/yr)
Employer:
To (mo/yr)
Address:
Compensation
(per hour):
Immediate
Supervisor:
Reason for leaving:
Phone:
Email
Address:
Duties:
3
Work History Continued:
Job Title:
Full-time
Part-time
From (mo/yr)
Employer:
To (mo/yr)
Address:
Compensation
(per hour):
Immediate
Supervisor:
Reason for leaving:
Phone:
Email
Address:
Duties:
4
Job Title:
Full-time
Part-time
From (mo/yr)
Employer:
To (mo/yr)
Address:
Compensation
(per hour):
Immediate
Supervisor:
Reason for Leaving:
Phone
:
Email
Address:
Duties:
5
List community or professional organizations in which you hold membership, leadership position, license, and/or
registration: (Do not include any that would reveal race, religion, physical handicap, marital status, or ancestry.)d
reveal race, religion, physical
REFERENCES:
List the names of at least three references who know you and have direct knowledge of your work and that you
give permission for CASBHC to contact.
NAME
OFFICIAL POSITION
BUSINESS TELEPHONE
May we contact your current employer?
Yes
No
If your answer is no, please explain below:
Are you a U.S. citizen or permanent resident? Yes
If not, please provide an explanation.
No
Have you ever been convicted of a felony? Yes
No
If yes, please provide explanation below. Such an admission will not automatically
ban you from employment.
6
NOTICE TO ALL APPLICANTS
In 1986, the United States Congress passed the Immigration Reform Control Act (IRCA). This law prohibits
employers from hiring persons who are not legally authorized to be employed in the United States. The law also
requires employers to examine documents which prove that persons hired after November 6, 1986, are legally
authorized to be employed in the United States. The law also requires employers to examine documents which
prove that persons hired after November 6, 1986, are legally authorized to work. Failure to provide the document(s)
will result in termination of employment. This applies to all persons hired.
The Immigration Reform and Control Act requires that verification of employment eligibility be
documented for all new employees by the end of the third day of work.
ACCEPTABLE DOCUMENTS
If hired, you will be required to submit documents such as:
U.S. Passport
State Drivers License
Certificate of
Naturalization
ID Card with photo
OR
Alien Registration Card
with photo
U.S. Military Card
School ID Card with photo
Original Social Security Card
AND
Birth Certificate, with seal
issued by state, county or
municipality
American Indian Tribal
Documents
Job-related Background Checks
Job-related background checks will be conducted and completed before appointment
to a position. Your submission of this application is your consent and authorization
for the Colorado Association for School-Based Health Care or its authorized agent to
conduct a background investigation prior to employment. Background checks are
mandated for all individuals. Background checks may include criminal history,
identity check and/or fingerprinting.
Applicant Signature and Date:
___________________________________________________________
Signature
___________________
Date
7