Southeast Missouri Behavioral Health E-Application Form  

Employment E-Application Form

If you are interested in applying, please fill out the following and click Submit at the bottom of the page.
Please do not hit Enter while the cursor is outside of a textbox, as this will hit the Submit button and submit the information filled out.


As part of our pre-employment procedures, you will be required to successfully complete a urine drug test. You will also be required to fill out certain pre-employment forms at the time of your interview. This application will remain active for no more than 90 days from the date it was made.
Southeast Missouri Behavioral Health does not discriminate in employment on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran, or military status.

Personal Information

Your Email Address
First Name
Middle Initial/Name
Last Name
Maiden Name
Secondary Phone
Present Address
Present City
Present State
Present Zip Code
Permanent Address
Permanent City
Permanent State
Permanent Zip Code
Check if you are 21 years or older
Check if you are a US citizen or an alien
authorized to work in the United States
Do you have a Facebook or similar social networking site?

If you have a resume to upload please do so here:

Please only use .DOC, .DOCX, .TXT, or .PDF files less than 5MB in size.
The Age Discrimination in Employment Act of 1987 prohibits discrimination on the basis
of age with respect to individuals who are at least 40 years of age.

In case of emergency notify


Employment Desired

Positions in this column require a minimum of a High School diploma (or equivalent).
Check position(s) for which you are applying:
Positions in this column have specific educational, licensing, credentialing, and/or experience requirements.

Check position(s) for which you are applying:
Behavioral Health Technician/Community Reentry Technician
Medication Room Technician
House Supervisor
Group Facilitator
Food Service Worker
Administrative Assistant
Licensed Professional Counseleor/Licensed Clinical Social Worker
Care Coordinator
Community Education Specialist
Substance Abuse Counselor
Case Manager, Community Reentry Services
Social Services Coordinator, Community Reentry Services
Registered Nurse/Licensed Practical Nurse
Director/Assistant Director
Performance Improvement Analyst
Information Technology
Billing Supervisor
Management Analyst
Community Prevention Specialist
Other position not listed above:
I give consent to be considered for other job positions:
Date you can start
Salary/Pay desired
Have you ever applied to SEMO BH before?
Have you been employed previously by SEMO BH?
Are you employed now?
If so, may we inquire of your employer?
Referred by
Do you know anyone at this company?
(leave blank for none, list the name if yes)
Are you related to anyone at this company?
(leave blank for none, list the name if yes)
Have you ever been convicted of a felony?
Answering Yes will not automatically disqualify you from employment
If Yes, please explain


Name and Location of SchoolNumber of years attendedDid you graduate?Subjects StudiedDegreeOther degree
High School
Trade, Business, or Correspondence School
College 2
College 3


Subjects of special study or research work

Special Skills

Keyboarding Words per Minute:   10 Key Entry  
Microsoft Access   Microsoft Word  
Microsoft Excel  
Any other software with which you are familiar
Any other skills you feel would be applicable
Professional licenses and number information
Professional certificates and expiration
Any other relevant training or certificates
Activities (civic, athletic, etc.)
Exclude organizations, the name of which indicates the race,
creed, sex, age, marital status, color, or nation of origin of its members
U.S. Military or Naval Service

Present membership in National Guard or Reserves
Please supply DD214 at interview

Former Employers

List below your last four employers, starting with the last one first

Date, Month and YearName, Address, and
Phone Number of Employer
SalaryPositionReason for Leaving




Which of these jobs did you like the best and why?

Personal References

Give the names and phone numbers of three persons not related to you, whom you have known at least one year.

NamePhone NumberBusiness (Name and City)Years Aquainted

Professional References

Give the names and phone numbers of three persons not related to you, whom you have known at least one year.

NamePhone NumberBusiness (Name and City)Years Aquainted

This agency is required by Federal Law to report specific information regarding our applicant pool for our Affirmative Action Program. The completion of each item is strictly voluntary. The information will be used exclusively for our internal monitoring and reporting to Federal agencies. Your cooperation is greatly appreciated.

NOTE: None of the information supplied below will be used in the employment process. This information will be separated from the application and will be used exclusively in our reporting requirements to the Federal Agencies.

Ethnic Origin: American Indian/Alaskan Native - A person having origins in any of the original peoples of North America, and who maintains cultural identification through tribal affiliation or community recognition.
If American Indian/Alaskan Native, please designate tribal affiliation:
Veteran Status: Do you claim coverage under the Americans with Disabilities Act (ADA)?

I decline to answer these voluntary questions:

By clicking submit I certify that the facts contained in my application for employment with Southeast Missouri Behavioral Health, Inc., are true and complete to the best of my knowledge. I understand that if employed, falsified statements on the application shall be grounds for dismissal.

I authorize investigation of all statements contained herein, of the references listed on my application, and of any other documents given to Southeast Missouri Behavioral Health, Inc. for pre-employment purposes. I authorize the individuals and businesses listed as references to provide Southeast Missouri Behavioral Health, Inc. any and all information concerning my previous employment and any other pertinent information they may have. I understand Southeast Missouri Behavioral Health may extend to me a conditional offer of employment that is dependent on results of a drug screening and background checks that may include present and prior history with: The Missouri Department of Health and Senior Services (Family Care Safety Registry); (driving record); the Worker’s Compensation Division of the Missouri Department Labor and Industrial Relations (Worker’s Compensation claims); and the United States Department of Justice (fingerprint background check). I understand the results of the drug screening and background checks will influence the conditional offer of employment.

By clicking submit, I hereby release forever all parties from all liability for any damage that may result from furnishing information to Southeast Missouri Behavioral Health, Inc..

I understand and fully agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice and without cause.