ONLINE EMPLOYMENT FORM

********** Gateway Healthcare, Inc. is a SMOKE FREE Organization **********

APPLICATION FOR EMPLOYMENT
All Applicants For Employment Are Required To Complete This Form

Last Name	First Name	Middle Inital

Address 1	Address 2	City

State	Zip Code	Email

Phone	Fax	SSN
		(This will be collected at interview)

Position Applied For

Date of Application

Have You Ever INTERVIEWED With Gateway?

Yes No

If So, Give Date:

Have You Ever Been EMPLOYED With Gateway or Any Gateway Agency?

Yes No

If So, Provide Date(s) and Agency:

How Did You Hear About Us?
If Employee Referral, please list employee:

Advertisement	Job/Career Fair	Internet
Employee Referral	Employment Agency	Walk-In
Other:

Date Available For Work:

****** REFERENCES ******
REFERENCES MUST BE CURRENT AND/OR FORMER SUPERVISORS.
DO NOT LIST THE NAMES OF ANY FRIENDS OR RELATIVES.

Reference 1:
Name:		Relationship:
Address:		Phone:

Reference 2:
Name:		Relationship:
Address:		Phone:

Reference 3:
Name:		Relationship:
Address:		Phone:

EMPLOYMENT/EXPERIENCE

Begin with your present or last job. Include any job related military service assignments and volunteer activities. Gateway Healthcare, Inc. will contact the employers listed below as part of the agency's background investigation of all prospective employees. Do not leave any sections blank, you must complete this section.

Employer	Dates Employed
	Date From: Date To:
Address	City	State

Zip	Phone	Fax

Job Title	Hourly Rate/Salary	Supervisor

Reason For Leaving	Job Duties/Responsibilities

Employer	Dates Employed
	Date From: Date To:
Address	City	State

Zip	Phone	Fax

Job Title	Hourly Rate/Salary	Supervisor

Reason For Leaving	Job Duties/Responsibilities

Employer	Dates Employed
	Date From: Date To:
Address	City	State

Zip	Phone	Fax

Job Title	Hourly Rate/Salary	Supervisor

Reason For Leaving	Job Duties/Responsibilities

EDUCATION

	Name and Address of School	Course of Study	Years Completed	Diploma/Degree
Elementary
High School
College
Graduate
Other

INDICATE ANY LANGUAGE YOU CAN SPEAK, READ AND/OR WRITE, INCLUDING ENGLISH
	FLUENT	GOOD	FAIR
SPEAK
READ
WRITE

DESCRIBE ANY SPECIALIZED TRAINING, APPRENTICESHIP, SKILLS, EXTRA CURRICULAR ACTIVITIES, AND VOLUNTEER SERVICES WHICH YOU BELIEVE ENHANCE/RELATE TO THE ABILITIES NECESSARY FOR THE POSITION BEING SOUGHT.

LIST PROFESSIONAL, TRADE, BUSINESS, OR CIVIC ACTIVITIES AND OFFICES HELD WHICH YOU BELIEVE ENHANCE/RELATE TO THE ABILITIES NECESSARY FOR THE POSITION BEING SOUGHT.

All offers of employment are *conditional* until information on this form has been checked. GHI may revoke any offer of employment if it finds that the applicant's responses are false, misleading or incomplete in any way. Offers of employment with Gateway is made solely by GHI's Human Resources representatives. Gateway is subject to numerous legal and ethical requirements related to the health and safety of its employees and consumers. As one mechanism to assure compliance with some of these requirements, all applicants are required to complete the following. A "false" to any of the below does not necessarily disqualify a person from employment.
1. I have never been convicted of any crime.	True False
2. I have never been convicted of a felony.	True False
***If "False", please explain:

3. I am not included on Rhode Island's child abuse and neglect tracking system (CANTS).	True False
4. I do not have, nor have I ever had, a consumer or business relationship with any Gateway Provider.	True False
***If "False", please explain:

5. To my knowledge, no one in my family ("family" shall be defined as spouse, partner, brother, sister, or parent) or an individual with whom I have a close personal relationship has or has had a business or consumer ("consumer" shall be defined as individuals who are receiving or have received clinical services) relationship with a Gateway Provider.	True False
6. I have not been sanctioned/penalized by any agency of the federal government.	True False
7. If I am a licensed professional, my license is current and I am in good standing with my professional organization in Rhode Island.	True False
8. **If you are under 16 Years of age, can you provide required proof of Your Eligibility to work?	N/A True False
9. Are you authorized to work for any company in the United States of America? Proof of citizenship or immigration status will be required upon employment	True False

We consider applicants for all positions without regard to race, color, religion, creed, or gender, national origin, age, disability, marital status or veteran's status, sexual orientation, or any other legally protected status.

We Are An Equal Opportunity Employer

I certify that the answers given herein are true and complete to the best of my knowledge.

I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

I Authorize Do Not Authorize GHI to contact the employers listed herein, and to request and obtain any such information it deems relevant to the employment decision.

I hereby understand and acknowledge that any employment with GHI is of an "at will" nature, which means that I may resign at any time and that GHI may discharge me at any time with or without cause. I also understand that no policy, manual or other document, conduct, or representation by or on behalf of GHI can change the "at will" nature of my employment unless and until an authorized executive of GHI expressly states in writing that the nature of my employment is changing to other than "at will" and the executive signs it is his/her official capacity.

I understand that a BCI background check will be conducted. I understand that if I am applying for a position within a children's/substance abuse program, a CANTS/BCI background check will be conducted. I understand that employment is contingent on the results of a CANTS and/or BCI background check.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand also that I am required to abide by all rules and regulations of the Employer.

By my clicking the button below below, I certify that the above information is accurate. I understand that any offer of employment will be conditional until the above information has been confirmed. If GHI finds that any of the above information is false, misleading or incomplete, it may be revoked, even if such determination is made after I start work.