Counterpoint, Inc. · Counterpoint, Inc. Employment Application

Counterpoint, Inc. | 116 E. Lewis Street, Livingston MT 59047

(406) 222-2472 | counterpointinc.org | info@counterpointinc.org

Nurturing personal growth and

supporting meaningful lives

since 1976

Date

*

(mm/dd/yyyy)

CONTACT INFORMATION

Name

*

First Name

Last Name

Email

*

Verify Email

*

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Phone

*

EMPLOYMENT

Date(s) available

*

Position(s) applying for

*

Have you ever applied for a job here before?

*

Yes

No

If Yes, give date(s)

Have you ever been employed here before?

*

Yes

No

If Yes, give date(s)

Do you have a valid Montana Driver's License

*

Yes

No

Will you accept:

Full Time

*

Yes

No

Part Time

*

Yes

No

Substitute

*

Yes

No

Weekends

*

Yes

No

Morning Hours (6am-9am)

*

Yes

No

Daytime Hours (8am-5pm)

*

Yes

No

Evening Hours (4pm-10pm)

*

Yes

No

Overnight Hours

*

Yes

No

EDUCATION

Last High School Attended

Name & Location (City, State) of School

Major/Minor Field of Study

Degree / Certificate

G.E.D.

Name & Location (City, State) of School

Major/Minor Field of Study

Degree / Certificate

College/University/Vocational

Name & Location (City, State) of School

Major/Minor Field of Study

Degree / Certificate

CHECK ANY OF THE FOLLOWING SKILLS OR CERTIFICATIONS YOU HAVE:

CPR

Yes

First Aid

Yes

Computer

Yes

10 Key

Yes

Manual Sign Language

Yes

DDCPT or Equivalent

Yes

MANDT

Yes

Medical Certification

Yes

Other Skills / Certifications

EMPLOYMENT EXPERIENCE

Start with your present or last job and go back a minimum of (5) years, listing former employers.

You may include military service assignments and volunteer activities.

1. Employer's Name

Address (Street, City, State, Zip)

Job Title

Supervisor

Phone

Start Date

End Date

Wage

Reason for Leaving

Duties Performed

2. Employer's Name

Address (Street, City, State, Zip)

Job Title

Supervisor

Phone

Start Date

End Date

Wage

Reason for Leaving

Duties Performed

3. Employer's Name

Address (Street, City, State, Zip)

Job Title

Supervisor

Phone

Start Date

End Date

Wage

Reason for Leaving

Duties Performed

4. Employer's Name

Address (Street, City, State, Zip)

Job Title

Supervisor

Phone

Start Date

End Date

Wage

Reason for Leaving

Duties Performed

5. Employer's Name

Address (Street, City, State, Zip)

Job Title

Supervisor

Phone

Start Date

End Date

Wage

Reason for Leaving

Duties Performed

PROFESSIONAL REFERENCES

(Most recent supervisors or instructors required. Do not list friends or relatives.)

1. Name

Address (Street, City, State, Zip)

Phone

Relationship

2. Name

Address (Street, City, State, Zip)

Phone

Relationship

3. Name

Address (Street, City, State, Zip)

Phone

Relationship

I hereby authorize Counterpoint, Inc. to inquire as to my record with any or all of my former employers with no liability arising therefrom. I hereby certify that all information above is true and complete to the best of my knowledge. I am aware that falsification or misrepresentation of required information is grounds for dismissal or disqualification from employment with Counterpoint, Inc.

Counterpoint, Inc. Employment Application

Counterpoint, Inc. | 116 E. Lewis Street, Livingston MT 59047

(406) 222-2472 | counterpointinc.org | info@counterpointinc.org

Nurturing personal growth and

supporting meaningful lives

since 1976

CONTACT INFORMATION

EMPLOYMENT

Will you accept:

EDUCATION

G.E.D.

College/University/Vocational

CHECK ANY OF THE FOLLOWING SKILLS OR CERTIFICATIONS YOU HAVE:

EMPLOYMENT EXPERIENCE

Start with your present or last job and go back a minimum of (5) years, listing former employers.

You may include military service assignments and volunteer activities.

PROFESSIONAL REFERENCES

(Most recent supervisors or instructors required. Do not list friends or relatives.)

COUNTERPOINT, INC. IS AN EQUAL OPPORTUNITY EMPLOYER