Instructions: Do not reply “yes” if the arrests or detention did not result in conviction, referrals to, and participation, in any pretrial or post-trial diversion program, marijuana-related convictions more than 2 years old; convictions for which the record has been judicially dismissed/sealed; and first convictions for misdemeanors of drunkenness, simple assault, speeding, minor traffic violations, or disturbances of the peace or misdemeanor convictions where 5 or more years have elapsed between the application date and the date of conviction of completion of incarceration, whichever is later. NOTE: A criminal conviction(s) may or may not constitute an automatic disqualification for employment.

I certify that all the information provided herein is true and complete to the best of my knowledge. I agree and understand that omissions, misstatements and falsifications may cause forfeiture on my part of all eligibility to any employment Harmony Behavioral Health and may be cause for rejection of this application, removal of my name from eligibility lists, or dismissal from employment. In addition, I give the Harmony Behavioral Health the right to verify any information obtained through the application process. Permission is granted and I release from any and all liability any employer, agency, individual, or educational institution assisting in providing relevant, job-related information to assist in the employment process. I understand a tuberculosis test is a requirement to work at Harmony Behavioral Health and agree to abide and present the necessary documentation of proof at the time of new hire. TB test must be in good standing one year prior to hire.

My signature below certifies that I have read and understand this application and agree to the terms and conditions outlined in this document.