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. Position for which you are applying: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 eligible to work in the U.S.?*YesNoSpecify any days or times you are not available for workCan 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 reliable form of transportation available to you to go to and from work?Please AnswerYesNoHave you ever been terminated from employment or asked to resign by an employer?Please AnswerYesNoIf yes, please provide company names and details:Are 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 DescriptionDate you can start employmentSalary ExpectationsAre you currently employedPlease AnswerYesNoMay we inquire of your present employer?Please AnswerYesNoEducationName and Location of School - 1Degree/Diploma Received - 1Number of Years Attended? - 1Please enter a number from 0 to 10.Subjects Studied/Major - 1Education (cont)Name and Location of School - 2Degree/Diploma Received - 2Number of Years Attended? - 2Please enter a number from 0 to 10.Subjects Studied/Major - 2Education (cont)Name and Location of School - 3Degree/Diploma Received - 3Number of Years Attended? - 3Please enter a number from 0 to 10.Subjects Studied/Major - 3Education (cont)Name and Location of School - 4Degree/Diploma Received - 4Number of Years Attended? - 4Please enter a number from 0 to 10.Subjects Studied/Major - 4Employment 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 PhoneAdditional InformationPlease provide any additional information or comments that may be relevant for the position.Resume Drop files here or Accepted file types: doc, docx, pdf, gdoc. Attach a resume and/or coverletterGogebic 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 PLEASE READ CAREFULLY BEFORE SIGNING. I understand and authorize Gogebic County Community Mental Health Services Authority to conduct a conviction only criminal history file search, and that I may be required to submit to a physical and back screen examination, which may include a drug test, prior to beginning employment and that I must satisfactorily pass such examinations to obtain employment. I understand that all the inquiries on this application are subject to electronic verification and periodic reverification and authorize any schools that I have attended, licensing and certification boards and current and previous employers to provide, by electronic means (including facsimile transmission and electronic transmission of information over the internet) Gogebic County Community Mental Health Authority, with any requested information. I also specifically waive written notice from any and all former employers regarding their disclosure to Gogebic County Community Mental Health Authority of any prior disciplinary action and waive any claim against Gogebic County Community Mental Health Authority and current or former employers arising from such investigation or disclosure. I further understand that neither the completion of this application nor any other part of my consideration for employment establishes any obligation for Gogebic County Community Mental Health Authority to hire me. If I am hired, I understand that either Gogebic County Community Mental Health Authority or I can terminate my employment at any time and for any reason, with or without cause and without prior notice. I understand that no representative of Gogebic County Community Mental Health Authority has the authority to make any assurance to the contrary. I attest with my signature below that I have given true and complete information on this application. No requested information has been concealed. I authorize Gogebic County Community Mental Health Authority to contact references provided for employment reference checks. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute the denial of employment or immediate dismissal. How did you learn about this job postingFacebookCMH websiteNewspaperIndeedLinkedinPlease wait for the confirmation message after submitting your application before leaving the page.
