Please enable JavaScript in your browser to complete this form.

Application for Employment - Step 1 of 7

Name *

First

Middle

Last

Phone *

Application Date *

Email *

Position & Availability

Position Applied For *

Position Type *

Regular / Volunteer *

Starting Salary Expectation *

Date of Availibility *

ARE YOU 18+ YEARS OLD? *

ARE YOU AVALIABLE TO WORK ALL HOURS AND DAYS? *

DO YOU HAVE A VALID DRIVERS LICENSE? *

ARE YOU ABLE TO PASS A DRUG SCREEN? *

ARE YOU ABLE TO PROVIDE DOCUMENTS SHOWING YOU ARE AUTHORIZED TO WORK IN THE U.S.? *

ARE YOU PHYSCIALLY ABLE TO PERFORM THE DUTIES FOR THE POSTION WHICH YOU ARE APPLYING? *

Yes
No
NOT SURE

ARE YOU ABLE TO PASS A CRIMINAL BACKGROUND SCREENING? *

(Criminal convictions shall not automatically disqualify applicants from employment)

IF NO TO ANY OF THE ABOVE, PLEASE EXPLAIN IN DETAIL, NOTING RESTRICTIONS, HISTORY & ALL CRIMINAL CONVICTIONS:

HAVE YOU EVER APPLIED FOR A POSTION WITH CIRQUE LODGE, INC. IN THE PAST? *

IF YES, WHEN DID YOU APPLY?

WERE YOU HIRED?

EDUCATION/TRAINING

CITY & STATE *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

PHONE NUMBER *

JOB TITLE *

ENDING PAY *

REASON FOR LEAVING *

EMPLOYMENT TIME

FROM (MO. / YR.) *

TO (MO. / YR.) *

TOTAL (YRS / MOS.) *

MAY WE CONTACT THIS EMPLOYER? *

NAME OF COMPANY *

CITY & STATE *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

PHONE NUMBER *

JOB TITLE *

ENDING PAY *

REASON FOR LEAVING *

EMPLOYMENT TIME

FROM (MO. / YR.) *

TO (MO. / YR.) *

TOTAL (YRS / MOS.) *

MAY WE CONTACT THIS EMPLOYER? *

NAME OF COMPANY

CITY & STATE

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

PHONE NUMBER

JOB TITLE

ENDING PAY

REASON FOR LEAVING

EMPLOYMENT TIME

FROM (MO. / YR.)

TO (MO. / YR.)

TOTAL (YRS / MOS.)

MAY WE CONTACT THIS EMPLOYER?

REFERENCE VERIFICATION

Please list 3 references that may be contacted on your behalf:

NAME OF REFERENCE *

JOB TITLE *

COMPANY *

PHONE *

NAME OF REFERENCE *

JOB TITLE *

COMPANY *

PHONE *

NAME OF REFERENCE *

JOB TITLE *

COMPANY *

PHONE *

Employee Medication Information

Employee Medication Information

Cirque Lodge does not hire anyone taking the following medications. All staff must remain free from these medications during their employ:

Suboxone, Subutex, Buprenorphine, Methadone, Lorazepam (Ativan), Diazepam (Valium), Chlordiazepoxide (Librium), Clonazepam (Klonopin), Nordazepam, Medazepam (Ansilan), Alprazolam (Xanax), Zolpidem (Ambien), Temazepam, Oxazepam (Serax), Flurazepam

Cirque Lodge must be notified if you are ever prescribed the following medications. You will be required to bring in a copy of your prescription and may not be able to work while taking it. You may be asked to speak with our Medical Director regarding the prescription:

Lortab, Percocet, Oxycodone, Hydrocodone Oxycontin, Fentanyl, Codeine, Darvocet, Demerol, Endocet, Roxicodone, Dilaudid, Hydromorphine, Morphine, Soma, Phenobarbital, Barbitutates, Norco

Cirque Lodge must be notified if you are ever prescribed the following medications. You will need to speak with our Medical Director regarding the prescription prior to you starting the medication and/or prior to starting employment:

Amphetamines, Adderall, Concerta, Vyvanse, Ritilan, Provigil, Nuvigil, Phentermine

I hereby certify that the information contained in this application is true and correct to the best of my knowledge and agree to have any statements checked by the Company unless I have indicated to the contrary. I authorize the references listed above, as well as all other individuals whom the Company contacts, to provide the Company any and all information concerning my previous employment and any other pertinent information that they may have. Further, I release all parties and persons from any and all liability for any damages that may result from furnishing such information to the Company as well as from the use or disclosure of such information by the Company or any of it’s agents, employees, or representatives. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive or offer or, if I am hire, my dismissal from employment. In consideration of my employment, I agree to conform to the rules and standards of the Company, as amended by the company from time to time in its discretion. In the event that the applicant agrees to accept a position with the company, the applicant and the company agree that employment relationship between the company and the employee is an at will relationship and that the employment relationship and compensation can be terminated, with or without cause, and with or without notice at any time, at the option of either the company or the employee. I also understand that all offers of employment are conditioned on the provision of satisfactory proof of an legal authority to work in the United States.

CIRQUE LODGE, INC. IS AN EQUAL OPPORTUNITY WITHOUT REGARD TO RACE, RELIGION, COLOR, NATIONAL ORIGIN, SEX, AGE, MENTAL OR PHYSICAL HANDICAP, MARITAL OR VETERAN’S STATUS.

Date

Print Name

Signature Required at Interview

Cirque Lodge Application

Position & Availability

EDUCATION/TRAINING

HIGH SCHOOL

College

College

Grad School

Trade School

EMPLOYMENT HISTORY

REFERENCE VERIFICATION

Employee Medication Information

Have any questions?

A Safe Place to Heal and Recover