Application Form

Applicant Information

Employment Position

Personal Information

Have you ever applied to or worked for The Foundry before?*
Do you have any friends, relatives, or acquaintances working for The Foundry?*
Are you 18 years of age or older?*
Are you a US citizen or approved to work in the United States?*
Will you consent to a mandatory urine drug screen?*
Have you ever been convicted of a criminal offense including a deferred judgment or sentence (felony or misdemeanor)?*
This job requires you to drive, is there any reason you would not be able to fulfil this obligation?*
Have you had any traffic violations in the last 7 years?*
Have you ever had any challenges to your licensure or registration?
Have you ever voluntarily or involuntarily relinquished your license or registration?
Have you ever voluntarily or involuntarily had a limitation, reduction, or loss of clinical responsibilities at another agency?
Have you ever been the subject of any professional liability action that resulted in a final judgement against you?

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Job Skills / Qualifications

(Note: THE FOUNDRY complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions.)

Education And Training

Are you a member of Armed Services?

Previous Employment

Can the Foundry contact this employer? References Please provide 3 personal and professional references

At-Will Employment

The relationship between you and THE FOUNDRY is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or THE FOUNDRY. No representative of THE FOUNDRY has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-¬will employment status, except for a written statement signed by you and either our Executive Vice-‐President/Chief Operations Officer or the Company's President.


Statement of Accuracy

• The relationship between you and THE FOUNDRY is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or THE FOUNDRY. No representative of THE FOUNDRY has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-¬will employment status, except for a written statement signed by you and either our Executive Vice-‐President/Chief Operations Officer or the Company's President.

• I certify that the answers given herein are true and complete to the best of my knowledge. I also authorize investigation of all statements contained in this application as may be necessary in arriving at an employment decision. In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge.

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