Employment Application — Divine Behavioral Solutions, Inc.

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Applicant Information

Full Name *

Email Address *

City, State, Zip *

Telephone *

Employment Position

Position Applying For *

How did you hear about this position?

What days are you available for work?

How soon can you start working?

Do you have reliable transportation? *

Yes No

Personal Information

Have you ever worked for D.B.S. before?

Yes No

Friends or relatives at D.B.S.?

Are you 18 years of age or older? *

Yes No

Valid ID or Driver's License? *

Yes No

Will you consent to a mandatory substance test?

Yes No

Do you need job accommodations?

Have you ever been convicted of a criminal offense?

Yes No

If yes, please describe

Note: No applicant will be denied employment solely on the grounds of a conviction. The date, nature, and relevance to the position may be considered.

Job Skills & Qualifications

List your relevant skills and qualifications *

Education & Training

High School Name

High School Location

Year Graduated

Degree / Diploma Earned

College / University Name

College Location

Year Graduated

Degree Earned

Vocational / Specialized Training

Training Location

Year Completed

Certification / Degree Earned

Military Service

Are you a member of the Armed Services?

Yes No

Branch of Military

Rank When Discharged

Years of Service

Military skills relevant to this position?

Previous Employment

Employer 1 (Most Recent)

Employer Name

Job Title

Supervisor Name

Employer Telephone

Employer Address

Dates Employed

Reason for Leaving

Employer 2

Employer Name

Job Title

Supervisor Name

Employer Telephone

Employer Address

Dates Employed

Reason for Leaving

Employer 3

Employer Name

Job Title

Supervisor Name

Employer Telephone

Employer Address

Dates Employed

Reason for Leaving

References

Please provide 3 personal and/or professional references.

Reference 1

Name *

Contact Info *

Reference 2

Name *

Contact Info *

Reference 3

Name *

Contact Info *

Acknowledgment & Consent

Document Uploads

Please upload clear photos of the following documents. You can use your phone camera — just make sure the full document is visible and the text is readable.

Accepted file types: JPG, PNG, or PDF. Max file size: 5MB per file.

Driver's License or State ID — Front *

Driver's License or State ID — Back *

Social Security Card *

Additional Document (if requested by DBS)

Required Tax & Government Forms

The following forms are required by federal and state law. Please download each form, complete it, and either bring it to your first day of work or email it to Patrick.surrell.dbs@gmail.com.

How to Fill Out These Forms on Your Phone

No printer needed! You can fill out, sign, and email every form right from your phone. Just follow the steps for your device below.

🍎 iPhone / iPad

Step 1: Tap the download button for the form you need.

Step 2: When the PDF opens in your browser, tap the Share button (the square with an arrow pointing up).

Step 3: Tap "Save to Files" and pick a location (like "On My iPhone" or "iCloud Drive"). Then tap Save.

Step 4: Open the Files app on your phone and find the form you just saved.

Step 5: Tap the form to open it. You'll see it open in a preview — tap on any blank field and your keyboard will pop up so you can type in your information.

Step 6: For signature fields, tap the field and use your finger to sign on screen. If that doesn't work, tap the markup icon (pen tip icon at top right) and use the pen tool to sign.

Step 7: When you're done filling everything out, tap the Share button again, then tap "Mail" or "Gmail" and send it to Patrick.surrell.dbs@gmail.com.

🤖 Android

Step 1: Tap the download button for the form you need. The PDF will download to your phone.

Step 2: When the download finishes, tap the notification at the bottom or top to open the file. If you miss it, open your Files app or My Files app and look in the Downloads folder.

Step 3: The PDF should open in Google Drive PDF Viewer or your default PDF app. If prompted to choose an app, pick Google Drive PDF Viewer or Adobe Acrobat Reader (free in the Play Store if you don't have it).

Step 4: Tap on any blank field to start typing your information. The form fields are interactive — just tap and type.

Step 5: For signature fields, tap the signature area. In Adobe Reader you can tap "Fill & Sign" at the bottom, then "Create Signature" and draw your signature with your finger.

Step 6: When you're done, tap the three dots (⋮) in the top right corner and select "Share" or "Send file". Choose your email app and send the completed form to Patrick.surrell.dbs@gmail.com.

Tip: If you have trouble filling out a form on your phone, try downloading the free Adobe Acrobat Reader app from the App Store or Google Play — it works great with all of these forms.

W-4 Form (2026)

Federal Tax Withholding

Employee's Withholding Certificate — tells your employer how much federal income tax to withhold from your pay. This PDF is fillable on your phone or computer — no printing needed.

Download W-4

MS Withholding Certificate

Mississippi State Tax

Mississippi Employee's Withholding Exemption Certificate — determines your state income tax withholding. Fillable PDF — complete on your device and email back.

Download MS Form

Form I-9

Employment Eligibility

Employment Eligibility Verification — verifies your identity and authorization to work in the United States. Fillable PDF — complete Section 1 on your device before your first day.

Download I-9

Direct Deposit Authorization

Banking Information

Direct deposit setup form with your bank details. Fillable on your phone or computer — email to Patrick.surrell.dbs@gmail.com or bring to your first day.

Print Form

Note: All four forms above are fillable PDFs — you can complete them directly on your phone or computer without printing. Once filled out, email them to Patrick.surrell.dbs@gmail.com.

Electronic Signature

Type your full legal name *

Date *

Draw Your Signature Below *

Your information is sent securely and reviewed by our hiring team.