Online Employment Application
An Equal Opportunity Employer
107 South 5th Street
Richmond, Virginia 23219 3825
Human Resources (804) 819 4099
Fax (804) 819 8720

• Personal Data •

Full Name: 

Address:  

Last 4 Digits of Social Security Number:

Telephone Number:
Home: Work:

Email address/Web address:


Are you under 18 yrs of age?

If any of your employment or education has been under a different last name, please indicate below:


Can you, upon employment (actual start date), submit verification of your legal right to work in the US?

If No, Please explain in Additional Information, Page 4. (Proof of employment eligibility will be required upon employment.)

The RBHA is an equal opportunity employer. Qualified applicants are considered for vacancies without regard to race, color, religion, sex, national origin, age, disability, veteran status, or other status legally protected by applicable law. The RBHA will reasonably accommodate the disabilities of qualified applicants to permit them to perform the essential functions of the subject position.

The RBHA prohibits its employees from using illegal drugs, being intoxicated on the job and distributing, dispensing, possessing or using controlled substances/intoxicants in the workplace. As a condition of employment, submission to a pre-employment drug-screening test for illegal drug use is required as part of our hiring process.

• Position Data •

Position(s) / Location(s) for which you are applying:  

Salary/Hourly rate desired:

Date available for employment:

How did you learn about the RBHA?

Are you currently being considered for any other position(s) at the RBHA?

If yes, which positions and for what group/location:

Have you ever worked for the RBHA?

If yes, when, what position, and group/location:

Have you been convicted of a felony; a misdemeanor involving lying, cheating or stealing; or a misdemeanor involving moral turpitude, that has not been annulled, expunged or sealed by a court? (A conviction does not automatically eliminate you from employment consideration. View Barrier Crime information)

If yes, please explain:

Have you been convicted of a DUI, reckless driving, or had a suspension and/ or revocation of your driver’s license in the last 5 years? (A conviction does not automatically eliminate you from employment consideration. View Drivers Safety information)


If yes, please explain:

• Education and Training Data •

High School

Name

Address 

Did you graduate?  

Degree

College

Name

Address

Did you graduate?

Degree

Major

Minor

Units req'd for degree 

Units completed


Correspondence or Trade School
Name
Address
Did you graduate?
Degree
Major/Degree
 		Minor
Units req'd for degree
Units completed

Graduate School or Additional Undergraduate
Name
Address
Did you graduate?
Degree
Major/Degree
 		Minor
Units req'd for degree
Units completed

 

Certification(s)/License(s) Certifying/Licensing Organization Date certified/Licensed

***A copy of required license(s), certification(s) must be provided as a condition of hire.

Accomplishments/Training: Professional, Academic, Personal Please list any additional information you consider pertinent to your application for employment.  Describe unique accomplishments, scholastic honors, honorary societies, patents, professional publications, professional registrations, professional society memberships, certifications, licenses, or other job-related knowledge, skills or qualifications.

Please complete this section only if appropriate to the position(s) for which you are applying:

Personal Computer hardware and software type(s):

 Approximate keyboard speed

Average typing speed (WPM) (if applicable)

List any additional skills, licenses, equipment used in Additional Information Section, page 4

? References ?

Give names of 3 or more people we may contact (former supervisors if possible). 
All should have specific knowledge of your work experience and/or capabilities.

1.  
Name
Current Position
Employer
Address
Phone Daytime
Phone Evening
Relationship
Years Known

2.
Name
Current Position
Employer
Address
Phone Daytime
Phone Evening
Relationship
Years Known

3.
Name
Current Position
Employer
Address
Phone Daytime
Phone Evening
Relationship
Years Known

4.
Name
Current Position
Employer
Address
Phone Daytime
Phone Evening
Relationship
Years Known

5.
Name
Current Position
Employer
Address
Phone Daytime
Phone Evening
Relationship
Years Known

Relatives Employed by the RBHA or on the RBHA Board of Directors: Name/Where/When Employed?

? U.S. Military Service Data ?

 
Branch
From/To
Last Rank
Specialty
Honorable Discharge?
Present Reserve Status or Obligation

1.

2.

3.


Unemployment Periods
During past 10 years, if there are any unemployment periods of a month or more between schooling, military, or employed periods, please list the dates, along with the names and addresses of persons other than relatives who can confirm this information.  Use Additional Information Section if more room is needed.

From (mo. /yr.)

To (mo. /yr.)

Name (Last, First, Middle)

Address (City, State, ZIP)

Employment Data (Begin with most recent)

All information must be completed.  You may attach a resume but not in place of completing required information.

List all jobs, activities, and other experience, including volunteer work, part-time employment while in school, U.S. Military service, and self-employment for the past 10 years.  Please indicate if you have ever used another name for employment purposes during this period.  Salary information will be verified if hired.  Use Additional Information Section if necessary.


Employer
 Supervisor
 Sup Phone Number
Street Address
Job Title
Title
From
 		To
Base Rate
$ / 		Bonus
Reason for leaving/Still Employed
Description of Duties

May we contact this employer for references?

May we contact you at your present place of employment?

If yes, please enter your:

Work Phone

Extension

Employer
 Supervisor
 Supervisor Phone Number
Street Address
Job Title
Supervisor Title
From
 		To
Base Rate
$ / 		Bonus
Reason for leaving/Still Employed
Description of Duties

Employer
 Supervisor
 Sup Phone Number
Street Address
Job Title
Supervisor Title
From
 		To
Base Rate
$ / 		Bonus
Reason for leaving/Still Employed
Description of Duties

Employer
 Supervisor
 Sup Phone Number
Street Address
Job Title
Supervisor Title
From
 		To
Base Rate
$ / 		Bonus
Reason for leaving/Still Employed
Description of Duties

Employer
 Supervisor
 Sup Phone Number
Street Address
Job Title
Supervisor Title
From
 		To
Base Rate
$ / 		Bonus
Reason for leaving/Still Employed
Description of Duties

Employer
 Supervisor
 Sup Phone Number
Street Address
Job Title
Supervisor Title
From
 		To
Base Rate
$ / 		Bonus
Reason for leaving/Still Employed
Description of Duties

Employer
 Supervisor
 Sup Phone Number
Street Address
Job Title
Supervisor Title
From
 		To
Base Rate
$ / 		Bonus
Reason for leaving/Still Employed
Description of Duties

Employer
 Supervisor
 Sup Phone Number
Street Address
Job Title
Supervisor Title
From
 		To
Base Rate
$ / 		Bonus
Reason for leaving/Still Employed
Description of Duties

Employer
 Supervisor
 Sup Phone Number
Street Address
Job Title
Supervisor Title
From
 		To
Base Rate
$ / 		Bonus
Reason for leaving/Still Employed
Description of Duties

*Base pay is your basic rate of pay excluding overtime pay, special bonuses or allowances.

Additional Information
Please list any additional information you consider to be job-related and pertinent to your application for employment (including scholastic honors, unique skills, professional publications, patents, foreign language capabilities, professional registrations, certifications and licenses.)  Attach additional pages as necessary.

• Personal Data Sheet •

VOLUNTARY SELF-IDENTIFICATION

The information requested below is voluntary and is used for statistical purposes only. The data collected is not used to make employment decisions and is kept in confidence.

If you choose not to provide this information about yourself, you will not be subject to adverse treatment of any type.  However, you should be aware that, in the absence of data provided by you, the agency is required by Federal Regulations to identify and maintain data on an applicant’s race, sex, veteran and disability status on the basis of visual observation.


Last Name First Name MI

Position for which you are applyingLocationDate
Name of Applicant (Last/First)Date

Please consider my status as follows (circle one code only for each grouping.)

Race/Ethnic Information See definitions

Veteran Information


Sex


EQUAL EMPLOYMENT OPPORTUNITY POLICY STATEMENT
The Richmond Behavioral Health Authority is committed to Equal Employment Opportunity (EEO).

The RBHA provides equal employment opportunities to all qualified employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability, or veteran status in accordance with state and federal laws.  This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, reinstatement, transfer, leaves of absence, compensation, benefits, and training.