General Information

Hidden

Date of Application

Are you at least 18 years of age(Required)

Yes

No

How did you hear about this job opening

Name(Required)

First Middle Last

Address(Required)

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

Telephone(Required)

Cell Phone

Email(Required)

Date you are available to start(Required)

Have you applied with Four County MHC before(Required)

Yes

No

If so, when(Required)

Have you ever been sanctioned by or excluded from Medicare or Medicaid programs? If so when?(Required)

Education

High School(Required)

Name/Location

Did you graduate

Degree/diploma

College

Name/Location

Did you graduate

Degree/diploma

Military/Other

Name/Location

Did you graduate

Degree/diploma

Graduate

Name/Location

Did you graduate

Degree/diploma

Employment

Employment From	Employment To	Company Name	Actions

There are no Past Jobs.

Professional References

Please list 3 previous employers. If you do not have 3, you may list former coworkers or contact who can couch for you in a professional or school setting.

References

Name	Phone	Email	Actions

There are no References.

Skills and Abilities

Please list below special skills, experiences, or qualifications you feel apply to the position in which you are interested. Click the plus sign to the right of the input field to add additional items.

Skills and abilities(Required)

Consent

Consent(Required)

I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by Four County Mental Health Center that such employment is at will, for no specified duration and may be terminated by either Four County MHC or myself at any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions, statements of Four County MHC or its representatives used during the employment process is deemed a contract of employment real or implied.

In consideration for employment with Four County MHC, if employed, I agree to conform to the rules, regulations, policies and procedures at all times and understand that such obedience is a condition of employment. I understand that due to the nature of Four County MHC business, attendance and punctuality are considered essential requirements of every job, and that poor attendance or tardiness will result in
disciplinary action.

I understand that if offered a position with Four County MHC, I may be required to submit to a drug screening and background check as a condition of employment. I understand that unsatisfactory results from refusal to cooperate with, or any attempt to affect the results of these pre-employments tests and checks will result in withdrawal of any employment offer or termination of employment if already employed.

I hereby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to Four County MHC and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information.

I acknowledge that I have read, understood, and agree to the above statements.(Required)

Signature(Required)