GMCS Application For Employment

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EMPLOYMENT APPLICATION

Grace & Mercy Community Services Mental Health Outpatient Clinic Behavioral Healthcare is an equal opportunity employer. It does not discriminate on the basis of race, color, religion, sex, national origin, age, disability , or any other characteristics protected by applicable state or federal civil rights laws.

AN EQUAL OPPORTUNITY EMPLOYER

DRUG SCREENING

Grace & Mercy Community Services Mental Health Outpatient Clinic is committed to maintaining a DRUG-FREE workplace. All offers of employment are contingent upon successful completion of a post-offer physical exam which includes drug screening.

BACKGROUND CHECK

Among other things, Grace & Mercy Community Services Mental Health Outpatient Clinic or Behavioral Healthcare is concerned about violence in the workplace, falsified employment applications, and employee theft. We will conduct a full background check on all candidates for employment..

E-VERIFY

Grace & Mercy Community Services Mental Health Outpatient Clinic or Behavioral Healthcare participates in E-Verify. E-Verify is used only to confirm work authorization after hire.

GENERAL INFORMATION

FIRST NAME*

MIDDLE NAME

LAST NAME

DATE

MM slash DD slash YYYY

ADDRESS

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

PREVIOUS ADDRESS

E-MAIL ADDRESS

HOME PHONE

WORK PHONE

AGE IF UNDER 18

IF HIRED, YOU WILL BE REQUIRED TO SUBMIT PROOF OF AGE IF UNDER 18 AND YOU WILL BE REQUIRED TO HAVE A VALID WORK PERMIT.

JOB INTEREST

FIRST CHOICE TITLE:

SECOND CHOICE TITLE:

DATE AVAILABLE

MM slash DD slash YYYY

SALARY DESIRED

HOURS & SHIFTS AVAILABLE:

FULL TIME

Yes

PART TIME

Yes

ON CALL

Yes

TEMPORARY

Yes

HOW MANY HOURS PER WEEK ARE YOU AVAILABLE?

DAY SHIFT

Yes

EVENING SHIFT

Yes

NIGHT SHIFT

Yes

PREVIOUS APPLICATIONS

HAVE YOU EVER APPLIED FOR A POSITION WITH Grace & Mercy Community Services Mental Health Outpatient BEFORE?

Yes

HAVE YOU APPLIED WITHIN THE LAST 6 MONTHS?

Yes

WERE YOU INTERVIEWED?

Yes

IF YES, WHAT POSITIONS HAVE YOU APPLIED FOR?

Yes

HOW WERE YOU REFERRED TO US?

(Publication)

Employee:

(Name)

School:

(Name)

Walk-In:

Are you able to perform the essential functions of the position for which you are applying, either with or without reasonable accommodation(s)? (Job description available for your review in Human Resources)

Yes

If necessary, please describe what type(s) of reasonable accommodation(s) is/are needed:

If under 18 years of age, please give date of birth:

If offered employment, can you submit verification of your legal right to work in the United States?

Yes

Have you previously been employed by Grace & Mercy Community Services Mental Health?

Yes

If yes, when?

Name worked under, if different:

Are you related to any present employee of Grace & Mercy Community Services MHO:

Yes

If yes, who?

Relationship:

MILITARY INFORMATION

WERE YOU EVER IN THE MILITARY?

Yes

IF YES, WHAT BRANCH?

WHAT RANK ATTAINED?

SPECIAL SKILLS AND TRAINING

THIS INFORMATION IS ONLY TAKEN INTO CONSIDERATION TO THE EXTENT THAT IT IS RELEVANT

SPECIFY NUMBER OF MONTHS/YEARS OF EXPERIENCE AND/OR SPEED

10 KEY (touch)

Yes

MEDICAL TERMINOLOGY

PBX (Type Board)

SHORTHAND (Speed)

Date last tested

MM slash DD slash YYYY

TYPING (Speed)

Date last tested

MM slash DD slash YYYY

WORD PROCESSING (Speed)

Date last tested

MM slash DD slash YYYY

Software used

SPREADSHEET (Software used)

Experienced on a computer system?

Yes

Describe:

PROFESSIONAL LICENSES / REGISTRATIONS / CERTIFICATIONS

TYPE

(If the position you are applying for requires a current license registration or certification, proof of same will be required.)

NUMBER

STATE ISSUED

DATE ISSUED

MM slash DD slash YYYY

EXPIRES ON

TYPE

(If the position you are applying for requires a current license registration or certification, proof of same will be required.)

NUMBER

STATE ISSUED

DATE ISSUED

MM slash DD slash YYYY

EXPIRES ON

Has your professional license ever been revoked or suspended?

Yes

If yes, when and why?

EDUCATIONAL RECORD

EDUCATION WILL BE CONSIDERED ONLY TO THE EXTENT THAT IT IS RELEVANT TO THE JOB YOU ARE APPLYING FOR

HIGH SCHOOL

ADDRESS

DIPLOMA

Yes

GED

ADDRESS

CERTIFICATE

Yes

COLLEGE

ADDRESS

MAJOR

DEGREE OBTAINED

Yes

COLLEGE

ADDRESS

MAJOR

DEGREE OBTAINED

Yes

OTHER EDUCATION, SPECIAL COURSES, OR ACADEMIC HONORS

LIST COURSES YOU ARE NOW ENROLLED IN WHICH RELATE TO THE POSITION(S) YOU ARE SEEKING, INDICATE WHERE ENROLLED.

NAME UNDER WHICH YOU WERE ENROLLED IF DIFFERENT FROM THAT SHOWN ON FRONT PAGE.

EMPLOYMENT HISTORY

MOST RECENT EMPLOYER FIRST - EXPLAIN LAPSES IN EMPLOYMENT BETWEEN JOBS

ACCOUNT FOR ALL TIME UP TO THE PAST 5 YEARS. Include military service in the United States Armed Services, voluntary services related to the position you are seeking, and every period of unemployment. If self-employed, give firm name, business activities undertaken by you, and one business reference that we may contact. DO NOT EXCLUDE EMPLOYMENT, NO MATTER HOW SHORT A PERIOD. If you need more space, additional pages are available. As further explained below, by signing this application, you permit Grace & Mercy Community Services Mental Health Outpatient to contact all of your previous employers.

PRESENT OR MOST RECENT EMPLOYER, VOLUNTARY ORGANIZATION, OR BRANCH OF SERVICE

IF STILL EMPLOYED, MAY WE CONTACT?

Yes

NAME UNDER WHICH YOU WORKED IF DIFFERENT FROM THAT SHOWN ON FRONT PAGE:

PHONE NO.

ADDRESS (Number, Street, City, State, Zip)

Employment

FULL TIME

PART TIME

AV. HRS. WKLY

JOB TITLE

IMMEDIATE SUPERVISOR

NAME:

TITLE:

NATURE OF DUTIES

EMPLOYMENT DATES

FROM

MM slash DD slash YYYY

HOURLY SALARY

START

($ per)

END

($ per)

REASON FOR LEAVING (Indicate resigned, discharged, etc. because of …)

*EXPLAIN TIME LAPSE HERE

PRESENT OR MOST RECENT EMPLOYER, VOLUNTARY ORGANIZATION, OR BRANCH OF SERVICE

IF STILL EMPLOYED, MAY WE CONTACT?

Yes

NAME UNDER WHICH YOU WORKED IF DIFFERENT FROM THAT SHOWN ON FRONT PAGE:

PHONE NO.

ADDRESS (Number, Street, City, State, Zip)

Employment

FULL TIME

PART TIME

AV. HRS. WKLY

JOB TITLE

IMMEDIATE SUPERVISOR

NAME:

TITLE:

NATURE OF DUTIES

EMPLOYMENT DATES

FROM

MM slash DD slash YYYY

HOURLY SALARY

START

($ per)

END

($ per)

REASON FOR LEAVING (Indicate resigned, discharged, etc. because of …)

*EXPLAIN TIME LAPSE HERE

PRESENT OR MOST RECENT EMPLOYER, VOLUNTARY ORGANIZATION, OR BRANCH OF SERVICE

IF STILL EMPLOYED, MAY WE CONTACT?

Yes

NAME UNDER WHICH YOU WORKED IF DIFFERENT FROM THAT SHOWN ON FRONT PAGE:

PHONE NO.

ADDRESS (Number, Street, City, State, Zip)

Employment

FULL TIME

PART TIME

AV. HRS. WKLY

JOB TITLE

IMMEDIATE SUPERVISOR

NAME:

TITLE:

NATURE OF DUTIES

EMPLOYMENT DATES

FROM

MM slash DD slash YYYY

HOURLY SALARY

START

($ per)

END

($ per)

REASON FOR LEAVING (Indicate resigned, discharged, etc. because of …)

PLEASE ANSWER ACCURATELY. WE CONDUCT FULL BACKGROUND CHECKS ON ALL CANDIDATES.

We will not deny employment to any applicant solely because the person has been convicted of a crime. We, however, may consider the nature, date, and circumstances of the offense as well as whether the offense is relevant to the duties of the position applied for.

Have you ever been convicted of a felony or a misdemeanor? (Please exclude convictions that have been sealed, expunged, or legally eradicated; and misdemeanor convictions for which probation was successfully completed or, otherwise, discharged and the case was judicially dismissed.)

Yes

If yes, please explain when you were convicted and for what you were convicted.

Have you ever been convicted of a felony or a misdemeanor under another name? (Note exclusions above.)

Yes

If yes, please give the name you used when convicted, when you were convicted, and for what you were convicted.

Are you presently out on bail or on recognizance pending trial for the alleged commission of any crime?

Yes

If yes, please explain.

Have you ever been convicted of a federal crime as defined in 42 U.S.C. §1320a-7a(I), or been excluded from participation in any federal or state health-care program?

Yes

PLEASE READ CAREFULLY APPLICANT'S CERTIFICATION. AGREEMENT AND NOTICE.

I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the 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 with 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 any use or disclosure of such information by the Company or any of its 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 an offer or, if I am hired, my immediate dismissal from employment.

I understand the Company may request me to submit to a pre-employment/post-offer medical examination and drug and alcohol screening tests; and I hereby agree and consent to such examination and testing. I understand any offer of employment is contingent upon my successfully passing the examination and testing.

I understand that employment is contingent upon my submitted documentary proof-of-identity and legal authorization to work in the United States, as required. Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. This employer will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Security (DHS), with information from each new employee's Form I-9 to confirm work authorization.

In consideration of my employment, I agree to conform to the rules and standards of the Company. I further agree that my employment and compensation can be terminated at will, with or without cause, and with or without notice, at any time, either at my option or at the option of the Company. I understand that no employee or representative of the Company, other than its CEO, has the authority to enter into any agreement for employment for any specified period of time, or to make any express or implied agreement contrary to the foregoing. Further, the CEO of the Company may not alter the at-will nature of the employment relationship or enter into any employment agreement for a specified time unless the CEO and I both sign a written agreement that clearly and expressly specifies the intent to do so. I agree that this shall constitute a final and fully binding integrated agreement with respect to the at-will nature of my employment relationship and that there are no oral or collateral agreements regarding this issue.

I understand that if an employment relationship is established, the Company retains the absolute right to transfer, demote, and administer employee discipline at any time for any reason and that nothing contained in the Company's personnel policies or procedures can be construed to the contrary.

I further understand that all offers of employment are conditioned on the Company's receipt of satisfactory responses to reference requests and the provision of satisfactory proof of an applicant's identity and legal authority to work in the United States. Offers of employment are also conditioned on the satisfactory completion of a post-offer medical examination.

Date*

MM slash DD slash YYYY

Signature of Applicant*

Grace & Mercy Community Services Mental Health Outpatient

EEO APPLICANT FLOW DATA FORM

Dear Applicant:

Federal and state rules require that we keep applicant flow data in our records for statistical purposes. Employers are asked to solicit this information from applicants on a purely voluntary basis. The information is not used for any employment decision.

If you wish to provide this information, please do the following:

Do not place your name on this sheet.
Enter the date below.
Check the applicable boxes and enter your date of birth.

This form will not be kept with your employment application.

Today's Date:

MM slash DD slash YYYY

Position Applied for:

I am:

Hispanic or Latino: a person of Cuban, Mexican, Puerto Rican, Central or South American, or

Not Hispanic or Latino

If you checked "Not Hispanic or Latino", please check one of the following racial/ethnic categories:

American Indian or Alaska Native: a person having origins in any of the original peoples of North, South and Central America, and who maintain cultural identification through tribal affiliation or community attachment

Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American: a person having origins in any of the Black racial groups of Africa.

Native Hawaiian or Other Pacific Islander: a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White: a person having origins in any of the original peoples of Europe, the Middle East or North Africa.

Two or More: a person who identifies with more than one of the above five races.

I am:

Female

Male

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