BCTT

BEHAVIORAL HEALTH REFERRAL
Community Facilitator Registration
HUMAN RESOURCES
PARENT GROUP PRE/POST TEST
PARENTING GROUP REGISTRATION
PCL-5 PTSD Checklist
PHQ-9 Depression Screener
PROGRAMS
School Drug Diversion Consent Form
SCHOOL SURVEY
Service Ticket

BEHAVIORAL HEALTH REFERRAL
Community Facilitator Registration
HUMAN RESOURCES
PARENT GROUP PRE/POST TEST
PARENTING GROUP REGISTRATION
PCL-5 PTSD Checklist
PHQ-9 Depression Screener
PROGRAMS
School Drug Diversion Consent Form
SCHOOL SURVEY
Service Ticket

Employment Application

Thank you for taking an interest in employment opportunities with Building Communities Today for Tomorrow, Inc. Below is our employment application. Submission of an application does not guarantee employment. If additional information is required, someone from our office will contact you.

Step 1 of 7

14%

Name(Required)

First Last

I need to:(Required)

DOCUMENT UPLOAD

I am uploading:(Required)

Auto Insurance

Auto Registration

CPR/First Aid (Required)

Driving Record

Photo Id (Required)

Professional License

SSC

Resume (Required)

Transcript/Degree/Diploma (Required)

Auto Insurance:(Required)

Drop files here or

Max. file size: 1 GB.

Auto Registration:(Required)

Drop files here or

Max. file size: 1 GB.

CPR/First Aid Training:(Required)

Drop files here or

Max. file size: 1 GB.

Driving Record:(Required)

Drop files here or

Max. file size: 1 GB.

Photo Id:(Required)

Drop files here or

Max. file size: 1 GB.

Professional License(s):(Required)

Drop files here or

Max. file size: 1 GB.

Resume/CV/Work History:(Required)

Max. file size: 1 GB.

SSC:(Required)

Max. file size: 1 GB.

Transcript/Degree/Diploma:(Required)

Max. file size: 1 GB.

DEMOGRAPHIC INFORMATION

Date of Birth:(Required)

MM slash DD slash YYYY

SSC/EIN:(Required)

SSN:(Required)

EIN:(Required)

Phone:(Required)

Email:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Active Military:(Required)

Branch:(Required)

From:(Required)

03/2021

To:(Required)

Ex: 05/2023

Rank at Discharge:(Required)

Type of Discharge:(Required)

If other than honorable, explain:

Date Available to Work:(Required)

MM slash DD slash YYYY

Desired Salary:(Required)

$15.00 per hour, $32,000.00 annually

Position Applied For:(Required)

Are you a US Citizen?(Required)

If no, are you authorized to work in the U.S.?(Required)

Have you ever worked for this company?(Required)

If yes, when?(Required)

EDUCATION

High School Name & Location:(Required)

ABC High School, West Virginia

Start Date:(Required)

Ex: 09/2005

End Date:(Required)

Ex: 09/2009

Did you graduate:(Required)

College Name & Location:

ABC High School, West Virginia

Start Date:

Ex: 09/2005

End Date:

Ex: 09/2009

Did you graduate:

Degree Type:

Other Name & Location:

ABC High School, West Virginia

Start Date:

Ex: 09/2005

End Date:

Ex: 09/2009

Did you graduate:

Degree Type:

CRIMINAL HISTORY

Have you ever been convicted of a criminal offense (felony or misdemeanor)?(Required)

Please state the nature of the crime(s), when and where conviction took place and disposition of the case:(Required)

REFRENCES

Provide 3 professional references.

Name(Required)

First Last

Relationship:(Required)

Company:(Required)

Phone:(Required)

Email:

Name(Required)

First Last

Relationship:(Required)

Company:(Required)

Phone:(Required)

Email:

Name(Required)

First Last

Relationship:(Required)

Company:(Required)

Phone:(Required)

Email:

EXPERIENCE & PREVIOUS EMPLOYMENT

Company:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Supervisor:(Required)

Supervisor Phone:(Required)

Job Title:(Required)

Responsibilities:(Required)

Starting Salary:(Required)

Ending Salary:(Required)

Start Date:(Required)

09/2022

End Date:(Required)

03/2023

Reason for Leaving:(Required)

Contact Number:(Required)

May we contact your previous supervisor for a reference?(Required)

Company:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Supervisor:

Supervisor Phone:(Required)

Job Title:(Required)

Responsibilities:(Required)

Starting Salary:(Required)

Ending Salary:(Required)

Start Date:(Required)

09/2022

End Date:(Required)

03/2023

Reason for Leaving:(Required)

Contact Number:(Required)

May we contact your previous supervisor for a reference?(Required)

Company:

Address

Street Address Address Line 2 City State ZIP Code

Supervisor:

Supervisor Phone:

Job Title:

Responsibilities:

Starting Salary:

Ending Salary:

Start Date:

09/2022

End Date:

03/2023

Reason for Leaving:

Contact Number:

May we contact your previous supervisor for a reference?

Do you have reliable transportation?(Required)

Avalialibity:(Required)

	Mornings	Afternoons	Evenings	N/A
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

EMERGENCY CONTACT

Name:(Required)

First Last

Phone:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Name:

First Last

Phone:

Address

Street Address Address Line 2 City State ZIP Code

UPLOADS

I'm uploading:(Required)

Nothing at this time

Auto Insurance

Auto Registration

CPR/First Aid (Required)

Driving Record

Photo Id (Required)

Professional License

SSC

Resume (Required)

Transcript/Degree/Diploma (Required)

Auto Insurance:(Required)

Drop files here or

Max. file size: 1 GB.

Auto Registration:(Required)

Drop files here or

Max. file size: 1 GB.

CPR/First Aid Training:(Required)

Drop files here or

Max. file size: 1 GB.

Driving Record:(Required)

Drop files here or

Max. file size: 1 GB.

Photo Id:(Required)

Drop files here or

Max. file size: 1 GB.

Professional License(s):(Required)

Drop files here or

Max. file size: 1 GB.

Resume/CV/Work History:(Required)

Max. file size: 1 GB.

SSC:(Required)

Max. file size: 1 GB.

Transcript/Degree/Diploma:(Required)

Max. file size: 1 GB.

CONSENTS

Acknowledgment of the following is required for the application process for U.S.D. 112. This document must be signed to complete the application.1. I certify that all the information provided by me in this application is true and complete. I understand that any misstatement, falsification, or omission of information is grounds for refusal to hire or, if I am hired and the same is discovered thereafter, termination.2. I authorize any of the persons or organizations referenced in this application to give you any and all information concerning my previous employment, education, or any other information, personal or otherwise, with regard to any of the subjects covered by this application, and I release all such parties from all liability for any damages that may result from furnishing such information to you. I authorize any background checks by any third party. 3. I authorize you to request, receive, and verify all information given on this application and I release you from all damages that may result from your doing so.4. I authorize you to conduct a criminal background investigation using any and all methods necessary to successfully complete such investigation and I release you from all liability for any damages that may result from your doing so.

Signature(Required)

Step 1 of 7

14%

Name(Required)

First Last

I need to:(Required)

DOCUMENT UPLOAD

I am uploading:(Required)

Auto Insurance

Auto Registration

CPR/First Aid (Required)

Driving Record

Photo Id (Required)

Professional License

SSC

Resume (Required)

Transcript/Degree/Diploma (Required)

Auto Insurance:(Required)

Drop files here or

Max. file size: 1 GB.

Auto Registration:(Required)

Drop files here or

Max. file size: 1 GB.

CPR/First Aid Training:(Required)

Drop files here or

Max. file size: 1 GB.

Driving Record:(Required)

Drop files here or

Max. file size: 1 GB.

Photo Id:(Required)

Drop files here or

Max. file size: 1 GB.

Professional License(s):(Required)

Drop files here or

Max. file size: 1 GB.

Resume/CV/Work History:(Required)

Max. file size: 1 GB.

SSC:(Required)

Max. file size: 1 GB.

Transcript/Degree/Diploma:(Required)

Max. file size: 1 GB.

DEMOGRAPHIC INFORMATION

Date of Birth:(Required)

MM slash DD slash YYYY

SSC/EIN:(Required)

SSN:(Required)

EIN:(Required)

Phone:(Required)

Email:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

Active Military:(Required)

Branch:(Required)

From:(Required)

03/2021

To:(Required)

Ex: 05/2023

Rank at Discharge:(Required)

Type of Discharge:(Required)

If other than honorable, explain:

Date Available to Work:(Required)

MM slash DD slash YYYY

Desired Salary:(Required)

$15.00 per hour, $32,000.00 annually

Position Applied For:(Required)

Are you a US Citizen?(Required)

If no, are you authorized to work in the U.S.?(Required)

Have you ever worked for this company?(Required)

If yes, when?(Required)

EDUCATION

High School Name & Location:(Required)

ABC High School, West Virginia

Start Date:(Required)

Ex: 09/2005

End Date:(Required)

Ex: 09/2009

Did you graduate:(Required)

College Name & Location:

ABC High School, West Virginia

Start Date:

Ex: 09/2005

End Date:

Ex: 09/2009

Did you graduate:

Degree Type:

Other Name & Location:

ABC High School, West Virginia

Start Date:

Ex: 09/2005

End Date:

Ex: 09/2009

Did you graduate:

Degree Type:

CRIMINAL HISTORY

Have you ever been convicted of a criminal offense (felony or misdemeanor)?(Required)

Please state the nature of the crime(s), when and where conviction took place and disposition of the case:(Required)

REFRENCES

Provide 3 professional references.

Name(Required)

First Last

Relationship:(Required)

Company:(Required)

Phone:(Required)

Email:

Name(Required)

First Last

Relationship:(Required)

Company:(Required)

Phone:(Required)

Email:

Name(Required)

First Last

Relationship:(Required)

Company:(Required)

Phone:(Required)

Email:

EXPERIENCE & PREVIOUS EMPLOYMENT

Company:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Supervisor:(Required)

Supervisor Phone:(Required)

Job Title:(Required)

Responsibilities:(Required)

Starting Salary:(Required)

Ending Salary:(Required)

Start Date:(Required)

09/2022

End Date:(Required)

03/2023

Reason for Leaving:(Required)

Contact Number:(Required)

May we contact your previous supervisor for a reference?(Required)

Company:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Supervisor:

Supervisor Phone:(Required)

Job Title:(Required)

Responsibilities:(Required)

Starting Salary:(Required)

Ending Salary:(Required)

Start Date:(Required)

09/2022

End Date:(Required)

03/2023

Reason for Leaving:(Required)

Contact Number:(Required)

May we contact your previous supervisor for a reference?(Required)

Company:

Address

Street Address Address Line 2 City State ZIP Code

Supervisor:

Supervisor Phone:

Job Title:

Responsibilities:

Starting Salary:

Ending Salary:

Start Date:

09/2022

End Date:

03/2023

Reason for Leaving:

Contact Number:

May we contact your previous supervisor for a reference?

Do you have reliable transportation?(Required)

Avalialibity:(Required)

	Mornings	Afternoons	Evenings	N/A
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

EMERGENCY CONTACT

Name:(Required)

First Last

Phone:(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Name:

First Last

Phone:

Address

Street Address Address Line 2 City State ZIP Code

UPLOADS

I'm uploading:(Required)

Nothing at this time

Auto Insurance

Auto Registration

CPR/First Aid (Required)

Driving Record

Photo Id (Required)

Professional License

SSC

Resume (Required)

Transcript/Degree/Diploma (Required)

Auto Insurance:(Required)

Drop files here or

Max. file size: 1 GB.

Auto Registration:(Required)

Drop files here or

Max. file size: 1 GB.

CPR/First Aid Training:(Required)

Drop files here or

Max. file size: 1 GB.

Driving Record:(Required)

Drop files here or

Max. file size: 1 GB.

Photo Id:(Required)

Drop files here or

Max. file size: 1 GB.

Professional License(s):(Required)

Drop files here or

Max. file size: 1 GB.

Resume/CV/Work History:(Required)

Max. file size: 1 GB.

SSC:(Required)

Max. file size: 1 GB.

Transcript/Degree/Diploma:(Required)

Max. file size: 1 GB.

CONSENTS

Signature(Required)