Employment Application Your Information EHS does not discriminate on the basis of race, religion, color, national origin, age, veteran, family status, sex, or sexual identity. OK Question Title * 1. Which office are you applying for? Christiansburg (NRV) Lynchburg Martinsville Roanoke OK Question Title * 2. Position applying for: MHSS Clinician MHS Team Leader Clinical Coordinator Office Manager SA Program Manager SA Counselor SA Case Manager Physician Level (Physician, Nurse Practitioner, Physician Assistant) Other OK Question Title * 3. How did you hear of this position? Indeed EHS Website Facebook Current Employee Craigslist Other (please specify) OK Question Title * 4. Contact Information Full Name * Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Email Address * Phone Number * OK Question Title * 5. Date you're available to start work: Date Date OK Question Title * 6. Available: Full-time Part-time OK Question Title * 7. Do you have relatives working for EHS? Yes No If yes, please list: OK Question Title * 8. Have you ever been employed by EHS? Yes No If yes, when? OK Question Title * 9. If you have worked for EHS under another name, please list name(s): OK Question Title * 10. Do you have the legal right to work in the U.S.? Note: If hired, proof of identity and authorization to work in the U.S. will be required. Yes No OK Question Title * 11. Will you now or in the future require sponsorship for employment visa status? Yes No OK Question Title * 12. If applying for a position that requires driving a personal vehicle, do you have a valid license and proof of insurance? Yes No OK Question Title * 13. EHS Driver Safety Policy requires a motor vehicle record check for all employees who drive vehicles for related position duties. Do you have any driving offenses on your record? Yes No If yes, give details. (offense, place of occurrence, date, penalty) below. OK Note: Convictions are not an automatic bar to employment. Each case is considered on its individual merits and the position for which you have applied. However, false statements or material omissions will result in not being hired or terminated from employment. OK NEXT