This document is an employment application for Wellness Connections. It requests contact information, education history, employment history, references, languages spoken, experience working in behavioral health or with people with disabilities, and a signature certifying the truthfulness of the information provided. The applicant is applying for various open positions at Wellness Connections and signing that they understand the at-will nature of any potential employment and agree to follow company rules.

1. Wellness Connections
P.O. Box 2648
Sierra Vista, AZ 85636
Send email to: admin@wellness-connections.org
(520) 452-0080; Fax (520) 452-0090; Toll Free (866) 455-0080
Employment Application Date: / /______
Position(s) Applying for (1) __________________________ (2) _________________________
Name (Last) _______________________ (First) ______________________ (Middle Initial) ___
Address (Physical) _____________________________________________________________
(STREET) (City) (STATE) (ZIP)
Address (Mailing) _____________________________________________________________
(STREET) (City) (STATE) (ZIP)
Phone Number(s) _____________________________________________________________
(DAY) (EVENING) (CELL)
Email address ____________________________________________________________
Are you 21 years of age or older? ______ Social Security #_________________________
Driver’s License: #__________________ State________
When will you be available to start: __________ Are you willing to travel in state? __________
Are you prevented from lawfully becoming employed in this country because of VISA or Immigration
Status? YES_____ NO_____ Are you able to obtain a Fingerprint Card? YES_____ NO____
Signify location preference(s) (1, 2, 3, 4)
(Sierra Vista) ________ Mobile Outreach (Sierra Vista) ________ (Safford) ________ (Douglas)_______ (Nogales)_________
Other (specify) ________________________________________________________________
Signify time preference(s) (1, 2, 3 and 4)
Full Time____________ ¼ Time____________ ½ Time_____________ ¾ Time____________
Signify the hours you are available to work:
Application for Employment Page 1 Wellness Connections (Revised 7/2015)
Sun Mon Tue Wed Thu Fri Sat
From:
To:

2. Employment Application
Name (Last) _______________________ (First) ______________________ (Middle Initial) ___
How did you hear about SEACRS dba Wellness Connections?__________________________
Do you know anyone in our employ? NO_____ YES_____ If yes, who? ___________________
Are you related to anyone in our employ? NO_____ YES_____ If yes, who? ________________
Have you ever worked/volunteered with any one of the SEACRS Programs or Centers?
NO_____ YES_____ If yes, please specify__________________________________________
EDUCATION* Name & Location
# of
Years
Did You
Graduate?
Subjects Studied/
Major
Grammar School
High School
College
College
Trade, Business
CERTIFICATES/MILITARY/SPECIAL SKILLS etc. (please list)*
Do you have your Peer Support Specialist Certificate?_____ Yes? _____No?
What date were you certified?__________
Are you CPR/First Aide Certified? _____ Yes? Expires When?___________ _____No?
EMPLOYMENT**
(List last 3)*
Name/Location and
Contact
Salary Position
Reason for
Leaving
From:_________
(Present/Most Recent)
To:___________
From:_________
To:___________
From:_________
To:___________
*Use Supplied Supplemental Page if needed.
**Please attach your current Resume.
Application for Employment Page 2 Wellness Connections (Revised 7/2015)

3. Employment Application
Name (Last) _______________________ (First) ______________________ (Middle Initial) ___
Should be professional References/No family members.
REFERENCES* Name & Address Phone Relationship Years Acquainted
1
2
3
Do you speak and/or write languages other than English? NO_____ YES_____
If yes, please list_______________________________________________________________
Do you identify as a peer in the mental health arena, if so, what is your experience? *
____________________________________________________________________________
____________________________________________________________________________
Have you worked with people with disabilities?_______________________________________
How many months/years’ experience do you have in the behavioral health field? ____________
If you have been through a recovery experience, do you have 18 months of being clean and
sober? ______Yes _______No
Why do you want to work for us?*
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
“I certify that all of the information submitted by me on this application is true and complete, and I understand that if
any false information, omissions, or misrepresentations are discovered, my application may be rejected and, if I am
employed, my employment may be terminated at any time. In consideration of my employment, I agree to conform
to the company’s rules and regulations, and I agree that my employment and compensation can be terminated, with
or without cause, and with or without notice, at any time, at either my or the company’s option. I also understand
and agree that the terms and conditions of my employment may be changed, with or without cause, and with or
without notice, at any time by the company.”
_____________________________________________________________________________
(SIGNATURE) (DATE)
*Use Supplied Supplemental Page if needed.
Name (Last) _______________________ (First) ______________________ (Middle Initial) ___
SUPPLEMENTAL INFORMATION:
Application for Employment Page 3 Wellness Connections (Revised 7/2015)

4. Employment Application
Application for Employment Page 4 Wellness Connections (Revised 7/2015)