NORTHSIDE MENTAL HEALTH CENTER (813) BRUCE B. DOWNS BOULEVARD FAX: (813) TAMPA, FLORIDA 33612

Transcription

1 NORTHSIDE MENTAL HEALTH CENTER (813) BRUCE B. DOWNS BOULEVARD FAX: (813) TAMPA, FLORIDA EMPLOYMENT APPLICATION An Equal Opportunity Employer Drug Free Work Place NAME: Last First Middle Maiden/Prior ADDRESS: Number/Street Apt. # City State Zip TELEPHONE: Home: ( ) Work: ( ) Cell: ( ) Are you over age 18? Yes No Driver s License #: SOC. SEC. #: Are you either a U.S. citizen or an alien who has the legal right to reside and work in the U.S.? (You will be required to furnish proof of lawful work status if you are extended a job offer.) Yes No Have you ever been convicted of or pled guilty or nolo contendere to a felony or first degree misdemeanor? Yes No If yes, what charges? Where convicted? Date(s): NOTE: A yes answer to this question will not necessarily bar you from employment. The nature, severity and date of the offense in relation to the position for which you are applying will be considered. Is there anything that would prohibit you from performing the essential functions of the job, with or without reasonable accommodation? Yes No If yes, please explain: I am interested in employment: Full-time Part-time On-call I can begin work: Minimum salary acceptable: I am interested in a position as: Circle Highest Year of Education Completed: Grade School: High School: College: Graduate: Schools Names/Addresses Dates Attended Major Graduation Date Degree High School College or University (which campus ) Vocational, Professional, Or Graduate Professional, Other Schools Or Studies Revised: 3/06

2 EMPLOYMENT HISTORY Begin with your present or last job and describe in detail all periods of Employment or Non-employment for the past ten years 1. Name of Employer From (Mo) (Yr) To (Mo) (Yr) Address Your Job Title Full-time: Part-time Hours per week Starting Salary: Telephone # ( ) 2. Name of Employer From (Mo) (Yr) To (Mo) (Yr) Address Full-time: Part-time Hours per week Your Job Title Starting Salary: Telephone # ( ) 3. Name of Employer From (Mo) (Yr) To (Mo) (Yr) Address Full-time: Part-time Hours per week Your Job Title Starting Salary: Telephone # ( ) 4. Name of Employer From (Mo) (Yr) To (Mo) (Yr) Address Full-time: Part-time Hours per week Your Job Title Starting Salary: Telephone # ( ) 5. Name of Employer From (Mo) (Yr) To (Mo) (Yr) Address Full-time: Part-time Hours per week Your Job Title Starting Salary: Telephone # ( )

3 LICENSURE, REGISTRATION, SKILLS AND ADDITIONAL COMMENTS Use this space to add any information which would help evaluate your application, including any professional or occupational registration, licensure or certification you currently hold and may be required for employment (e.g., registered nurse s license). Also include special skills and additional comments: Computer Experience (Programs): Typing Speed: License Numbers or Certifications: NPI Number: REFERENCES: Please list below the names and addresses of persons we may contact for personal or professional references. Please name individuals to whom you are not related and have not been employed by. 1. Name Occupation Address Telephone # ( ) 2. Name Occupation Address Telephone # ( ) 3. Name Occupation Address Telephone # ( ) NOTE: The Department of Human Resources or any Department Director may contact any previous employer to verify your performance and description of past duties. May we contact your present employer? Yes No

4 EMPLOYMENT AT THE WILL OF NORTHSIDE MENTAL HEALTH CENTER: I understand that if employed, my employment will be at the will of the employer. In other words, there will be no employment contract, expressed or implied, and my employment may be terminated at any time at the will of Northside Mental Health Center. I,, understand that Northside Mental Health Center desires to check the information that I have provided on my application for employment. I understand that I am granting permission to Northside to obtain any information that any employer, any reference, or other person may have concerning my background, including verification of education, work records, criminal records of any felony convictions in the past five years and related data. I understand and agree that some of the information provided by me will be used by the local police authorities, the Florida Department of Law Enforcement, or others to check for felony convictions consistent with current law. I also understand that I must submit to a drug screen and Level II live scan finger printing. I also understand and agree that Northside requires me to provide information concerning previous work-related injuries and other injuries or conditions which might limit my ability to perform the particular job for which I am applying. This information will be used only to determine if I have a condition or handicap which affects my ability to work and assist Northside in accommodating such a limitation or handicap under federal and state employment laws, including the Florida Worker s Compensation Statutes, the Americans with Disabilities Act and the Rehabilitation Act of I hereby release Northside Mental Health Center, it s officers, directors, employees, agents, and any other person, company, or organization from any liability or damages which result from Northside s inquiries hereunder. I hereby certify that all statements made in this application are true, and I agree and understand that any misstatements of material facts herein will cause forfeiture on my part of all rights to any employment by Northside Mental Health Center. I further agree to a physical examination, if required, as a condition of my employment. History of physical conditions or limitations which might affect my ability to work: History of workers compensation injuries which might affect my ability to perform the essential functions of the job: Applicant s Signature Date:

5 NORTHSIDE MENTAL HEALTH CENTER EMPLOYMENT REFERENCE EMPLOYER: DATE: ADDRESS: PHONE: FAX: ATTENTION: Please verify the following information as given to us by your former employee, who has applied for a position with our organization. NAME: SOC. SEC. # DATES OF EMPLOYMENT: FROM: TO: POSITION(S): REASON FOR LEAVING: I authorize the above named employer to furnish Northside Mental Health Center with the information requested on this form. Applicant s Signature To Be Completed By Former Employer Is the above information correct? Yes No Eligible for re-hire? Yes No Please correct any discrepancies: Please evaluate the following: Excellent Good Average Fair Poor Performance/Quality of Work Accepts Supervision Attitude/Cooperation Emotional Stability Dependability/Attendance Overall Rating Comments: SIGNATURE: DATE: 1FORM006.APP

6 EQUAL EMPLOYMENT OPPORTUNITY REPORTING AND RESEARCH The following information is required for EEO reporting and analysis and will not be used to evaluate application. SOCIAL SECURITY NUMBER: DATE OF BIRTH: SEX: Female Male MARITAL STATUS: RACIAL/ETHNIC BACKGROUND: Asian or Pacific Islander Hispanic American Indian Black White Other ARE YOU ADA (Americans with Disabilities Act) QUALIFIED? YES NO Explain HOW WERE YOU REFERRED TO NORTHSIDE MENTAL HEALTH CENTER Advertisement Tampa Tribune Employment Guide School/College Florida State Employment Services USF Oracle Northside Staff Member Other Advertisement (Please Specify) Other Agency (Please Specify) Other (Please Specify)