Job Application Form

Please complete information requested below. A member of our staff will contact you once information is reviewed.

"*" indicates required fields

Step 1 of 5

Table of Contents

Application for Employment

All applicants are considered for all positions without regard to race, religion, color, sex, gender, sexual orientation, pregnancy, age, national origin, ancestry, physical/mental disability, medical condition, military/veteran status, genetic information, marital status, ethnicity, citizenship or immigration status, or any other protected classification, in accordance with applicable federal, state, and local laws. By completing this application, you are seeking to join a team of hardworking professionals dedicated to consistently delivering outstanding service to our customers and contributing to the financial success of the organization, its clients, and its employees. Equal access to programs, services, and employment is available to all qualified persons. Those applicants requiring an accommodation to complete the application and/or interview process should contact a management representative.

Position(s) applied for*

Date of application*

Print full name*

First Last

Street address*

City*

State*

ZIP*

Main phone number*

Alt. phone number

Email*

Employment Experience

Please list the names of your present or previous employers in chronological order with present or most recent employer listed first. Be sure to account for all periods of time. If self employed, give firm name and supply business references. Add an additional page if necessary.

Name of employer*

Supervisor*

May we contact?*

Yes

Street address*

Employer Phone number

Dates employed from (month/year)*

YYYY

Dates employed to (month/year)*

YYYY

Job title and duties*

Reason for leaving*

Name of employer

Supervisor

May we contact?*

Yes

Street Address

Phone Number

Dates employed from (month/year)

Dates employed to (month/year)

Job title and duties

Reason for leaving

Name of employer

Supervisor

May we contact?*

Yes

Street Address

Phone Number

Dates employed from (month/year)

Dates employed to (month/year)

Job title and duties

Reason for leaving

Have you ever been involuntarily terminated or asked to resign from any job?*

Yes

If yes, please explain.*

Please explain any gaps in your employment history

Please list any other experience, job-related skills, additional languages, or other qualifications that you believe should be considered in evaluating your qualifications for employment.

Elevated Wellness Clinic

At Elevated Wellness Clinic in Maryland, we understand the journey to mental wellness is deeply personal. Our Elevated Wellness Clinic facility is designed to provide a serene, supportive environment, where every individual can find the path to their best self. Contact us to discover how we can help you or your loved ones on this journey to mental wellness.

Job Application Form

Application for Employment

Employment Experience

Education

High School

College/university

Graduate/professional school

Trade school

Other

Business and Professional References

Personal References

General Information

Applicant Statement and Agreement

Please read and initial each paragraph below. If there is anything that you do not understand, please ask.

Elevated Wellness Clinic

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