APPLICATION FOR EMPLOYMENT SEACOAST MENTAL HEALTH CENTER, INC. 1145 Sagamore Avenue Portsmouth, NH 03801-5585
30 Prospect Hill Exeter, NH 03833-1041
Seacoast Mental Health Center, Inc. is an equal opportunity employer and complies with all applicable laws prohibiting discrimination in hiring and employment. We are committed to a policy of non-discrimination and equal opportunity for all qualified applicants and employees. All employment decisions are made without regard to race, color, age, gender, religion, national origin, marital status, disability, veteran status, or sexual orientation. Name _______________________________________ Social Security # ______________________________ Mailing address with City, State, and Zip Code ___________________________________________________ Home Phone # ___________________________
Date of Application _________________
Position(s) for which you are applying_____________________________________________ ***************************************************************************************** * YES NO Are you at least 18 years of age?
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If no, can you furnish a work permit?
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Are you legally permitted to work in the United States?
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If hired, you will be required to submit proof of your identity and legal eligibility to work in the United States within 72 hours of your start date in compliance with The Immigration Reform and Control Act of 1986. Have you been convicted of any crime within the past five years? If yes, please explain on a separate sheet of paper. Please note that a conviction will not necessarily disqualify you from the job for which you have applied. Are you aware of any professional claims being brought against you within the last 10 years? If yes, please explain on a separate sheet of paper.
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Have you ever applied for employment at Seacoast Mental Health Center, Inc.? If yes, when? _________________
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Have you previously been employed by Seacoast Mental Health Center, Inc.? If yes, when? _________________
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EDUCATION Please circle the highest grade you have completed: 8
9
10
11
12
or
GED
13
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COLLEGE AND OTHER HIGHER EDUCATION Name of School
Address
Major
Degree or Certif. Earned
_____________________________________________________________________________________ _____________________________________________________________________________________ PROFESSIONAL CERTIFICATION/LICENSURE INFORMATION Type
Issuing State
Expiration Date
Current Cert./Lic. #
____________________________________________________________________________________ ____________________________________________________________________________________ If you are not licensed in the State of NH, have you applied? Yes ______ Date ______________
No _______
***************************************************************************************** EXPERIENCE - WORK HISTORY Please provide information regarding your experience and work history in the section below listing your most recent experience or position first. If you need additional space, attach a separate sheet of paper. If the information requested is contained on your resume, curriculum vitae, etc. you may reference it (i.e “see resume, vita”) and include it with the application. Employer______________________________________ Address _________________________________ City, State, Zip ____________________________________ Phone Number_________________________ Job Title _____________________________________ Supervisor's Name __________________________ Dates of Employment (from Mo./Yr. to Mo./Yr.) _______________________________________________ Please describe your position responsibilities __________________________________________________ _______________________________________________________________________________________ How many employees did you supervise? ___________________ Reason for leaving ___________________________________________________________
Employer____________________________________ Address _________________________________ City, State, Zip _________________________________________ Phone Number_________________ Job Title _______________________________ Supervisor's Name _____________________________ Dates of Employment (from Mo./Yr. to Mo./Yr.) ____________________________________________ Please describe your position responsibilities _______________________________________________ ___________________________________________________________________________________ How many employees did you supervise? ___________________ Reason for leaving ___________________________________________________________ **************************************************************************************** Employer____________________________________ Address _________________________________ City, State, Zip _________________________________________ Phone Number_________________ Job Title _______________________________ Supervisor's Name _____________________________ Dates of Employment (from Mo./Yr. to Mo./Yr.) ____________________________________________ Please describe your position responsibilities _______________________________________________ ___________________________________________________________________________________ How many employees did you supervise? ___________________ Reason for leaving ___________________________________________________________ ***************************************************************************************** Employer____________________________________ Address _________________________________ City, State, Zip _________________________________________ Phone Number_________________ Job Title _______________________________ Supervisor's Name _____________________________ Dates of Employment (from Mo./Yr. to Mo./Yr.) ____________________________________________ Please describe your position responsibilities _______________________________________________ ___________________________________________________________________________________ How many employees did you supervise? ___________________ Reason for leaving ___________________________________________________________ APPLICANT'S STATEMENT
I certify that the information on this application and any supporting documentation provided) is true and complete. I understand that any misrepresentation or omission may result in my disqualification from further consideration for employment or termination of my employment. Further, in order that Seacoast Mental Health Center, Inc. may process my application for employment, I hereby authorize Seacoast Mental Health Center, Inc., its subsidiaries, officers, directors, employees, representatives, and agents (hereinafter collectively referred to as “Seacoast”) to conduct a complete investigation into my background including, but not limited to, inquiring into my employment history; education history; credit history; criminal record and military record, if any; driving record; professional licensure/certification history and verification; to obtain opinions and references regarding my moral character and reputation and to solicit and obtain any other information Seacoast in its sole discretion deems as necessary to determine my eligibility for employment or for the purposes of confirming the accuracy and completeness of any information I provided to Seacoast. In consideration for the processing of my application for employment with Seacoast, I hereby release, indemnify and hold harmless Seacoast from any and all liability based on their authorized receipt, disclosure, and use of the information gathered in the processing of my application for employment. I further release from liability any person or organization that provides information concerning me. I understand that any employment offer will only be binding if it is in writing and signed by the Executive Director and any employment relationship that may be established shall be "at-will" and may be terminated by me or the Center at any time. I understand that, if hired, any offer of employment is contingent on production of proof of employment eligibility and a completion of a Form I-9. By my signature, I acknowledge that I have read and understand the foregoing and so authorize and release Seacoast.
SIGNATURE _____________________________________________________
File: HR/Admin/Recruitment/tmpJFMY8S ~ 3/30/98 Revised 10/27/98, 4/12/00, 2/21/02, 3/5/02, 11/21/02, 6/9/03, 6/6/05
DATE _______________