Application Form

* Please note * All fields marked with an asterisk ( * ) are required.

First Name *

Last Name *

Email Address

Address *

Cell Phone Number *

Home Telephone Number

Do you have a valid driver’s license? *

Have you had a driver’s license for at least 3 years? *

Position/Job ID Applying For *

Please Indicate Days You Are Available to Work (check all that apply) *

Work Schedule Desired (check all that apply)

Can you perform the essential functions of the position for which you are applying with or without reasonable accommodations? (if you have any questions as to what functions are relevant to the position to which you are applying please ask interviewer prior to answering.) *

How Did You Hear About Us? *

Name of Employee referred by (if applicable)

Are You 18 Years or Older? *

Have You Previously Been Employed By Walnut Street Center? *

If Previously Employed By Walnut Street Center, Please Provide Dates and Location

Cover Letter

To Submit Resume please copy and paste into box below

Education Level Achieved *

Please provide details of any licenses or certifications held

Do You Have Any of The Following Trainings?

Are You Currently Employed? *

Most Recent Employer *

Employer Number *

Dates Employed (mm/yyyy - mm/yyyy) *

Position Held and Description of Responsibilities *

Reason For Leaving *

Previous Employer

Employer Number

Dates Employed (mm/yyyy - mm/yyyy)

Position Held and Description of Responsibilities

Reason For Leaving

Professional Reference #1: Name *

Was this person a direct supervisor? *

Relationship *

Years Known *

Phone Number *

Professional Reference #2: Name *

Was this person a direct supervisor? *

Relationship *

Years Known *

Phone Number *

Briefly Describe Why You are Interested in Working at Walnut Street Center

Please read the below Applicant's Certification and Agreement Statement *

Note: In order to ensure that your application has been received, please make sure all required fields marked with an asterisk ( * ) are completed.

You will receive a confirmation of your application submission with a Check Marked Box above.

          PLEASE READ CAREFULLY BEFORE SUBMITTING

EEO POLICY

Walnut Street Center, Inc. and its subsidiaries and affiliates maintain a policy of non-discrimination for all employees and applicants in every facet of the company’s operations. In compliance with federal and state laws, Walnut Street Center, Inc. and its subsidiaries and affiliates hires, trains and promotes all qualified employees without unlawful discrimination on the basis of race, color, sex, sexual orientation, age, religion, marital status, citizenship, national origin, physical or mental handicap. This policy also applies to disabled veterans of the Vietnam Era.

Certifications

I understand and agree that this application is not a contract and that acceptance of employment is not a contract of employment for a specific term. I understand and agree that I may resign my employment with Walnut Street Center, Inc. and all its subsidiaries and affiliates at any time for any reason, and that my employment may be terminated at the will of Walnut Street Center, Inc. and its subsidiaries and affiliates at any time for any reason. I also understand that any handbooks, manuals, policies and procedures maintained by Walnut Street Center, Inc. and its subsidiaries and affiliates are not contractual in nature and may be amended or abolished at the sole discretion of Walnut Street Center, Inc. and all its subsidiaries and affiliates. I understand that to the extent that any policies and/or procedures set forth by Walnut Street Center, Inc. directly conflict with the terms of any applicable collective bargaining agreement (CBA) covering my position, the CBA shall govern.

Pursuant to the Immigration Reform and Control Act, Walnut Street Center, Inc. and all its subsidiaries and affiliates will employ only those individuals who are eligible to work in the United States. Accordingly, upon hiring, all new employees will be required to demonstrate their eligibility to work in the United States. Failure to do so will result in termination or revocation of the offer of employment.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil penalties.

I certify that I have read, understand and will adhere to the aforementioned statement.

I also certify that the information furnished in this application and any supporting documents is true and complete to the best of my knowledge and belief, and I understand that any misrepresentation or omission of material fact on this or on any other record submitted pertinent to employment will constitute grounds for immediate termination.

I hereby authorize my former employers, schools, persons listed herein to release information pertaining to my education or work record, my work habits and my work performance, and release Walnut Street Center, Inc. form any liability in connection with efforts to verify and/or receive references regarding my employment or educational history.

I hereby certify as follows: a) I have not been convicted of any criminal offense that precludes employment in a behavioral health provider; b) I am not excluded from participating in any federal health care or health care related programs; c) I am not listed on the List of Excluded Individuals/Entities of the Office of the Inspector General; and d) I am not listed on the Excluded Party List System of the General Services Administration