Chief Executive Officer Application The Community Mental Health Authority does not discriminate on the basis of race, color, religion, national origin, sex, age, height, weight, disability, or any other status protected by federal or state law or regulation. It is our intention that all qualified applicants be given equal opportunity and selection decisions be based on job-related factors. If you need assistance in completing this form because of disability, special accommodation for applications in alternative formats are available upon request. Name First Middle Last Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Phone NumberEmail Are you at least 18yrs of age or older?*YesNoAre you eligible to work in the U.S.?*YesNoCan you work any shift?YesNoCan you work overtime, including weekends?YesNoHave you ever been employed by Community Mental Health?YesNoIn what department and positionIf previously employed by Community Mental HealthDo you have a valid driver's license?Please AnswerYesNoAre you capable of performing with or without reasonable accommodation (special assistance, equipment or other help), the activities involved in the job or occupation for which you have applied?Please AnswerYesNoIf accommodations are needed, please explainAccommodation DescriptionEducationName and Location of School - 1Degree/Diploma Received - 1Number of Years Attended? - 1Please enter a number from 0 to 10.Did you graduate? - 1YesNoEducation (cont)Name and Location of School - 2Degree/Diploma Received - 2Number of Years Attended? - 2Please enter a number from 0 to 10.Did you graduate? - 2YesNoEducation (cont)Name and Location of School - 3Degree/Diploma Received - 3Number of Years Attended? - 3Please enter a number from 0 to 10.Did you graduate? - 3YesNoEducation (cont)Name and Location of School - 4Degree/Diploma Received - 4Number of Years Attended? - 4Please enter a number from 0 to 10.Did you graduate? - 4YesNoEmployment HistoryHow many employers have you have in the last five (5) years?Please choose the appropriate answerNoneOneTwoThreeFourFive (or greater)Current Employer's NameDates:month and yearAddress Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneSupervisor (Name and Title)Your Title:Duties and Responsibilities:Reason for leaving:Former Employer 1Former Employer's NameDates:month and year Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Supervisor (Name and Title)Your Title:Duties and Responsibilities:Reason for leaving:Former Employer 2Former Employer's NameDates:month and year Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Supervisor (Name and Title)Your Title:Duties and Responsibilities:Reason for leaving:Former Employer 3Former Employer's NameDates:month and year Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Supervisor (Name and Title)Your Title:Duties and Responsibilities:Reason for leaving:If Yes, State, #:, and Exp. DateProfessional/Work References:Please include at least 2 professional referencesName - 1 First Last Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneName - 2 First Last Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneName - 3 First Last Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code PhoneGogebic Community Mental Health Authority is an Equal Opportunity and an ADA Compliant Employer* I understand that checking this box constitutes a legal signature confirming all information provided on this application is true and accurate Salary ExpectationsAdditional InformationPlease provide any additional information or comments that may be relevant for the position.How did you learn about this job postingFacebookCMH websiteOnline Job PostingNewspaperPlease wait for the confirmation message after submitting your application before leaving the page.Resume Drop files here or Accepted file types: doc, docx, pdf, gdoc. Attach a resume and/or coverletter
