PLEASE READ THE FOLLOWING BEFORE COMPLETING OUR APPLICATION
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1. There is no guarantee of an interview or job offer after completing our application blank.
Your application will be considered with others who have submitted applications and
decisions about interviews will be based on this comparison.
2. Our application blank must be completely filled out for it to be considered for
employment.
3. Please do not include or attach a resume to the application blank. Do not say “Refer to
Resume” on the application blank. Should a resume be received, it will be immediately
destroyed and will not be considered in the application process.
4. If the information provided on our application cannot be satisfactorily verified by
employment reference checks, your application could be considered as incomplete.
5. If you submit a complete application blank and an interview is requested, you will be
contacted to schedule the interview in the time period allocated for interviews. If you are
no longer available for, or interested in, employment at MCBHC please decline the
interview request.
6. If you are interviewed and another candidate is offered and accepts the position, you will
receive written correspondence.
7. Due to the large number of received applications and the competitive nature of our
employment process, specific reasons for employment decisions will not be released.
It is understood and agreed upon that any misrepresentation by me on an application or
resume submitted for employment consideration will be sufficient cause for cancellation
of consideration and/or separation from the employer’s service if I have been employed.
I give the employer the right to investigate all references and to secure additional
information about me, if job-related. I hereby release from liability the employer and it’s
representing for seeking such information and all other persons, corporations, or
organizations for furnishing such information.
The employer is an Equal Opportunity Employers. The employer does not discriminate in
employment and no question on an application or during an interview is used for the
purpose of limiting or excusing any applicant’s consideration for employment on a basis
prohibited by local, state, or federal law.
This application submitted is current for 3 months. At the conclusion of this time, if I have
not heard from the employer and still wish to be considered for employment, it will be
necessary to fill out a new application.
I understand that just as I am free to resign at any time, the employer reserves the right to
terminate my employment at any time, with or without cause and without prior notice. I
understand that no representative of the employer has the authority to make assurances to
the contrary.
I understand it is this company’s policy not to refuse to hire a qualified individual with a
disability because of this person’s need for an accommodation that would be required by
the ADA.
Digital Signature
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Date
MM
DD
YYYY
Position (s) applied for
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Referral Source
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Advertisement
Employee
Relative
Government Employment Agency
Walk-in
Private Employment Agency
Other
Name of Source (if applicable)
Name
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First Name
Last Name
Address
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Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
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(###)
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If necessary, best time to call you at home is:
May we contact you at work?
Yes
No
If yes, work number and best time to call:
Email
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If you are under 18 and it is required, can you furnish a work permit?
Yes
No
Have you submitted an application here before?
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Yes
No
If yes, give dates and position(s):
Please list maiden name and/or any alias names, if applicable:
Are you or have you ever been excluded from Medicaid or Medicare reimbursement:
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Yes
No
If yes, please list the dates:
Date available for work:
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MM
DD
YYYY
Type of employment desired:
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Are you on lay-off and subject to recall?
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Yes
No
Will you work overtime if required?
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Yes
No
Will you travel if job requires it?
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Yes
No
If yes, please explain:
Do you possess a valid license?
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Yes
No
Employer
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Employer Phone
*
(###)
###
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Start Date
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MM
DD
YYYY
End Date
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Job Title
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Immediate Supervisor and Title
Reason for leaving
May we contact for reference?
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Yes
No
If no, what is reason?
Starting Hourly/Rate Salary
Ending Hourly Rate/Salary
Summarize the nature of the work performed and job Responsibilities:
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Employer
*
Employer Phone
(###)
###
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Start Date
*
MM
DD
YYYY
End Date
*
MM
DD
YYYY
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Job Title
*
Immediate Supervisor and Title
*
Reason for leaving
*
May we contact for reference?
*
Yes
No
If no, what is reason?
Starting Hourly/Rate Salary
*
Ending Hourly/Rate Salary
*
Summarize the nature of the work performed and job Responsibilities:
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Employer
*
Employer Phone
*
(###)
###
####
Start Date
*
MM
DD
YYYY
End Date
*
MM
DD
YYYY
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Job Title
*
Immediate Supervisor and Title
*
Reason for leaving
*
May we contact for reference?
*
Yes
No
If no, what is reason?
Starting Hourly/Rate Salary
*
Ending Hourly/Rate Salary
*
Summarize the nature of the work performed and job Responsibilities:
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Employer
*
Employer Phone
*
(###)
###
####
Start Date
*
MM
DD
YYYY
End Date
*
MM
DD
YYYY
Employer Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Job Title
*
Immediate Supervisor and Title
*
Reason for leaving
*
May we contact for reference?
*
Yes
No
If no, what is reason?
Starting Hourly/Rate Salary
*
Ending Hourly/Rate Salary
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Summarize the nature of the work performed and job Responsibilities:
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Comments (including explanation of any gaps in employment):
Skills and Qualifications-Summarize any special training, skills, licenses, certificates and/or characteristics of yourself that may qualify you as being able to perform job-related functions for the position which you are applying
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List last three (3) schools attended, starting with most recent.
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1. List the name of the school.
2. List number of years completed.
3. Indicate degree or diploma earned, if
any.
4. Major and minor of study (if applicable).
List any foreign language (s) you know and check the boxes that describe your skill level.
Let us know if you Speak Some, Speak Fluently, Read, and/or Write
Reference 1
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First Name
Last Name
Phone
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(###)
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Years Known
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Reference 2
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First Name
Last Name
Phone
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(###)
###
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Years Known
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Reference 3
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First Name
Last Name
Phone
*
(###)
###
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Years Known
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List any professional, trade, business, or civic associations and any offices held. (Exclude memberships, which would reveal sex, race,
religion, national origin, age, color, disability, or other protected status.)
List special accomplishments, publications, awards (exclude information which would reveal sex, race, religion, national origin, age, color,
disability, or protected status.)
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