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Personal Information

Previous Address


Education Name & Address of School Course of Study Years Completed Graduated? Degree or Diploma
High School

Note: a "yes" answer to any of the following questions does not automatically disqualify you from employment consideration

Employment — Must be completed in full

Please give accurate, complete full-time and part-time employment record. Start with present or most recent employer.






Complete this section if you served in the United States Armed Forces

Please note: NCSS is a service provider. To avoid any actual or potential conflict of interest, NCSS prefers not to provide services for employees, their immediate families or individuals residing in the same household with employees. (Reference HR Policy 127 - Employee Use of "In-house" Clinical Services). Please be aware, NCSS does not request or require that you disclose at this time whether services are being received from NCSS. Such conflict of interest issues may be discussed at a later time, if and when a conditional offer of employment is made.

As a general rule, where a person (or his or her family member, or person living in the same household) is receiving NCSS services, and then becomes an employee, we require transition to another provider as a condition of employment. For a more complete discussion of this policy, please contact the Human Resources Director at 524-6554 x6421. You will receive a confidential consultation regarding your options under HR Policy 127.


I certify that all information provided in this employment application is true, accurate and complete. I understand that any false or misleading information, including omission, intentional or unintentional, may disqualify me from further consideration for employment and may result in my dismissal if subsequently discovered.

I also understand that any offer of employment with NCSS is conditioned upon satisfactory results of criminal and motor vehicle background checks.

I further understand that acceptance of an offer of employment with NCSS does not create a guarantee of employment for a definite period of time or an obligation on NCSS’ part to continue to employ me in the future. I understand that if hired I have been hired at the will of NCSS and my employment may be terminated at anytime, with or without cause and with or without notice.

Authorization to Check References

I hereby authorize Northwestern Counseling & Support Services, Inc. (“NCSS”), or its agents/employees, to perform a check on my references and credentials, including verification of salary, degree(s), professional licenses, internship, residency, fellowship, experience, certification credentials, and any other background information, which may be requested in conjunction with my active candidacy for a position with NCSS. This check will include, but is not limited to, verbal or written communications and/or discussions with my past and/or current employer and/or supervisor(s), co-workers, friends, business associates, past and/or current educational institutions, or other individuals that NCSS, at its sole discretion, believes may have relevant information regarding my suitability for employment. I hereby agree to release and hold harmless NCSS, its agents and employees from any and all claims arising out of NCSS’ investigation of my references and credentials and any employment decisions made about me on the basis of information revealed by such investigation.

I also authorize all persons, institutions, organizations, and companies to whom this Authorization to Check References is presented to release and furnish to NCSS, its employees or agents any and all employment, education, credentialing and/or any other information sought in connection with this check. I hereby release and hold harmless any person, institution, organization, or company contacted by NCSS from any and all claims arising out of the release of information to NCSS in connection with its investigation of my references and credentials.


If this section is left blank, it is assumed that you can provide references upon request.


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