Position(s) applying for:     

Social Security #       Are you over 18?  Yes   No   If not, date of birth

Email address:      Telephone:     Cell:

Present Address     

Date Available:      Anticipated Pay:     Eligible for Employment is the U.S.? Yes   No

You are applying for:     Full-time   Part-time   Scheduled PRN   True PRN

Indicate availability for work:    Days  Evenings  Weekends  Nights  7a Shift  7p Shift

Have you worked for DMH before?  Yes  No       If yes, when & position(s)

Skills: Typing Computer Medical Terminology Calculator by touch Dictaphone Word Excel Powerpoint

Do you have a valid drivers license?  Yes  No                       Do you have any relatives employed at DMH?   Yes  No 

Have you ever been convicted of, had adjudication withheld, pled guilty or nolo contender (no contest) to a criminal offense (misdemeanor or felony), or are you currently under charges or on probation for any offense against the law?    Yes   No       If yes, please give complete details (date, place, charges, disposition, etc).   Please note:  We perform criminal background checks.  Falsification or omission of this or any other information on this application is grounds for denial of employment.

Complete High School or GED? Yes  No         Attend College?   Yes  No        Graduate from College? Yes  No     Graduate from School of Nursing?  Yes  No     Graduate from Technical School? Yes  No                                                  Where?    Degree or Certification:

Military Service:  Yes  No   Special training:   Dates of Service:

Professional Licenses:   Type:    Number:   State: Original Issue date:    Expiration Date:

Current Employment:

Company name:    Phone:  Fax:  City, State, Zip:     Employment Dates:      From   to   Job Title:   Supervisor: Wage/Salary: Name if different than present:   May we contact?    Yes  No                                                    Description of Duties:    Reason for leaving?       Explain employment gap:

Prior Employment:

Company name:    Phone:  Fax:  City, State, Zip:     Employment Dates:      From   to   Job Title:   Supervisor: Wage/Salary: Name if different than present:   May we contact?    Yes  No                                                    Description of Duties:    Reason for leaving?       Explain employment gap:

Prior Employment:

Company name:    Phone:  Fax:  City, State, Zip:     Employment Dates:      From   to   Job Title:   Supervisor: Wage/Salary: Name if different than present:   May we contact?    Yes  No                                                    Description of Duties:    Reason for leaving?       Explain employment gap:

Prior Employment:

Company name:    Phone:  Fax:  City, State, Zip:     Employment Dates:      From   to   Job Title:   Supervisor: Wage/Salary: Name if different than present:   May we contact?    Yes  No                                                    Description of Duties:    Reason for leaving?       Explain employment gap:

Prior Employment:

Company name:    Phone:  Fax:  City, State, Zip:     Employment Dates:      From   to   Job Title:   Supervisor: Wage/Salary: Name if different than present:   May we contact?    Yes  No                                                    Description of Duties:    Reason for leaving?       Explain employment gap:

Prior Employment:

Company name:    Phone:  Fax:  City, State, Zip:     Employment Dates:      From   to   Job Title:   Supervisor: Wage/Salary: Name if different than present:   May we contact?    Yes  No                                                    Description of Duties:    Reason for leaving?       Explain employment gap:

DMH considers all applicants without regard to race, color, religion, national origin, age marital status, veteran status, disability or other legally protected status.  If requiring a reasonable accommodation for interviewing purposes, please provide DMH with adequate notice in order to provide the accommodation(s). 

Agreement:

I understand and agree that:

• DMH makes every effort to accommodate employee preferences; however, staffing needs may mandate overtime, shift, department, position changes and/or rotating work schedules.  Failure to comply may result in termination.     

• I am responsible for all property assigned to me and for making arrangements for repayment of any debts owed to DMH.

•  If reasonable suspicion exists that I am under the influence of alcohol, drugs or other controlled substances, I will be requested to submit to a blood/urine drug test and/or alcohol test and that refusal or failure to do so will result in immediate discharge.  I also understand that if reasonable suspicion exists that I am in the possession of alcohol and;/or illegal drugs, I will be subject to questioning as well as a search of my work area; and that failure to cooperate will result in immediate discharge.  I understand lockers are DMH property and my permission is not required for search.

• I will comply with all current and future rules and regulations of DMH and I am responsible for understanding and adhering to all rules and any revisions that occur during the course of my employment.

• Employment is at will and subject to satisfactory performance.  This employment application and all DMH documents are not intended and should not be construed as a contract of employment, either expressed or implied, nor should they be construed to provide any guarantee or assurance of employment.  I understand that any oral or written statements to the contrary are hereby expressly disavowed.

•  I certify that all information given in this application is true to the best of my knowledge, and understand that any incorrect or misleading information, either by omission or commission, may be cause for immediate termination.  I grant permission to DMH to check my employment records at former employers and authorize former employers to release such information.  It is hereby agreed that no former employer, other person, or DMH will be held liable for releasing such information

• I certify that I have not been convicted of an offense that would preclude employment in a nursing or hospital facility.

 I have read and fully understand the above statements.

Applicant’s Signature  (double click signature area, select “OK” and digitally sign)

Date:

EQUAL OPPORTUNITY EMPLOYER

Drug and Alcohol Free Workplace 

Applicants are considered for employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, disabled, or other protected status.

 The following data is for statistical and government and reporting purposes only and will be kept in a Confidential File separate from the Application for Employment and will not be used in any employment decision.

Name:   Position applied for:

Referral Source: Newspaper  Internal Posting DMH Employee  Friend or Relative Employment AgencyOther

Date of Birth:    Male   Female

Race/Ethnic Group:   White  African American Hispanic/Latino   Asian Native Hawaiian/Other Pacific Islander               American Indian./Alaska Native  Two or more races

Education:    GED  High School Graduate  Trade/Technical School  Community College Graduate University Graduate