FOR OFFICE USE ONLY

Date

Letter

Reference Check by

Interview for

App #

EDUCATION High School Diploma or GED? [ ]Yes [ ]No (Verification will be required)

If no, circle highest grade completed 1 2 3 4 5 6 7 8 9 10 11 12

Name and location of business, correspondence, or

vocational school attended

FROM

Mo. Yr.

TO

Mo. Yr.

Did you

Graduate?

Area of

Study

Degree

Name and location of Colleges and Universities attended

FROM

Mo. Yr.

TO

Mo. Yr.

Did you

Graduate?

G.P.A.

Maximum

obtainable G.P.A.

Field(s) of Study

Major(s) Minors(s)

Degree

and Date

Graduate/Professional/Medical School

Residency/Internship/Fellowship

List professional certificates or licenses and state where issued

Is your license current and in good standing? Yes No

Educational subjects and/or training related to the duties of the position for which you are applying.

Sem. Hrs.

Qtr. Hrs.

Office/business machines operated

Software packages operated

Professional Memberships

Word processing preference

Typing Speed/WPM (net)

Have you ever been disciplined or counseled for harassment, attendance, or failure to follow policies? [ ] Yes [ ] No

Have you ever been involuntarily terminated, or forced to resign from a position (do not include layoffs)? [ ] Yes [ ] No

Have you ever been convicted of a moving vehicle violation (including speeding tickets & accidents) or

had your driver's license suspended or revoked within the past 5 years? [ ] Yes [ ] No

Have you ever been convicted of a crime? [ ] Yes [ ] No

Do you have any pending legal charges? [ ] Yes [ ] No

If you answered "Yes" to any of the above questions, attach an explanation on a separate sheet.

Can you, upon employment, submit verification of your legal right to work in the U.S.? [ ] Yes [ ] No

Are you 18 years of age or older? [ ] Yes [ ] No

If no, do you have a work permit? [ ] Yes [ ] No

1. Current or Last Employer

Your Official Job Title

Address

Type of Business

City State

Telephone

( )

From

Mo. Yr.

To

Mo. Yr.

If part-time,

number of hours

per week

Beginning Salary

$ per

Ending Salary

$ per

May we contact

employer?

[ ] Yes [ ] No

Name of Supervisor

Reason for Leaving

Describe your Duties

2. Current or Last Employer

Your Official Job Title

Address

Type of Business

City State

Telephone

( )

From

Mo. Yr.

To

Mo. Yr.

If part-time,

number of hours

per week

Beginning Salary

$ per

Ending Salary

$ per

May we contact

employer?

[ ] Yes [ ] No

Name of Supervisor

Reason for Leaving

Describe your Duties

3. Current or Last Employer

Your Official Job Title

Address

Type of Business

City State

Telephone

( )

From

Mo. Yr.

To

Mo. Yr.

If part-time,

number of hours

per week

Beginning Salary

$ per

Ending Salary

$ per

May we contact

employer?

[ ] Yes [ ] No

Name of Supervisor

Reason for Leaving

Describe your Duties

4. Current or Last Employer

Your Official Job Title

Address

Type of Business

City State

Telephone

( )

From

Mo. Yr.

To

Mo. Yr.

If part-time,

number of hours

per week

Beginning Salary

$ per

Ending Salary

$ per

May we contact

employer?

[ ] Yes [ ] No

Name of Supervisor

Reason for Leaving

Describe your Duties

5. Other Employers

From

Mo. Yr.

To

Mo. Yr.

Reason for Leaving

Describe in detail other clinical experience not included previously (including educational training such as clinical practica or internships)

REFERENCES

List three persons, unrelated to you, who can give information about you (preferably two persons who have supervised your work).

Name Occupation Phone

Street Address City State Zip Code

How do you know this person?

Name Occupation Phone

Street Address City State Zip Code

How do you know this person?

Name Occupation Phone

Street Address City State Zip Code

How do you know this person?

AGREEMENT

East Alabama Mental Health-Mental Retardation Center (hereafter referred to as "Center" is an equal opportunity employer. Federal law prohibits discrimination in employment practices because of race, color, religion, sex, national origin, citizenship status, age, pregnancy, or disability, if otherwise qualified with or without reasonable accommodation. No question on this application is asked for the purpose of limiting or excluding any applicant's consideration for employment because of his or her race, color, religion, sex, national origin, citizenship status, age, pregnancy, or disability.

I certify that all of the information given by me on this application or in supplemental form is true and correct to the best of my knowledge and belief. I further understand that false or misleading statements or consequential omissions of any kind on this application or supplemental forms are sufficient cause for my not being hired or my dismissal if I am hired.

I understand that if I am offered employment, such offer may be conditioned upon my taking a pre-employment physical. I understand that if I falsify my responses to medical inquires, including my history of worker's compensation claims, I may be terminated from employment and/or precluded from receiving worker's compensation benefits. I understand that I may be tested for controlled or illegal substances and that a positive test result may be grounds for termination and denial of worker's compensation and/or unemployment benefits. Furthermore, I understand that any employee or former employee who makes knowingly false or fraudulent material statements or misrepresentations for the purpose of obtaining worker's compensation benefits may be guilty of a felony.

I understand that any offer of employment will be contingent upon the Center's satisfaction with the results of the following as required for the position for which I am applying: medical history questionnaire, physical examination (when indicated by results of the medical questionnaire), motor vehicle record check, verification of insurability by any one of the Center's insurance companies (excluding health and dental carriers), criminal record check, drug screening, agreement to adhere to the Center's policies and procedures, completion of employment eligibility verification and official transcript or proof of licensure required for the position. The results of any physical examination will be considered for employment purposes only as it relates to the ability to perform the essential job functions of the position for which I might be employed. All results of physical exams are kept confidential.

I agree, understand and authorize that the Center or its agents may investigate my background to ascertain any and all information of concern to my record, whether same is of record or not. I authorize the persons or organizations referenced in this application to give the Center any and all information concerning my previous employment, education, or any other information they might have, personal or otherwise, with regard to any of the areas covered by this application. I release all such parties from all liability for any damage to me, my heirs or family that may result from furnishing such information to the Center.

It is agreed and understood that this Application for Employment in no way obligates the Center to employ me. If employed, I agree and understand that my employment is for no definite duration and may be terminated at-will by either the Center or me. It is agreed and understood by me that participation in any of the benefit programs of the Center does not create a contract of employment for a definite period of time. Additionally, the Center's Personnel Manual or any statement of Center policy is not a contract and cannot create a contract of employment for any definite duration.

In the event of my employment, any Center materials entrusted to me during the course of my employment will be returned to the Center on the last day of my employment, whether I resign or am terminated. I agree and understand, that should I be employed, I will not at any time or in any manner, either directly or indirectly, divulge, disclose, or communicate to any person, agency or corporation any matters affecting or relating to the business of the Center, including without limiting the generality of the foregoing, any of its consumers or customers, its services or products, its manner of operation, its plans, and any other "proprietary information". I understand that I will be asked to sign a confidentiality agreement consistent with this paragraph as a condition of employment.

This certifies that this application was completed by me, and all entries on it and information in it are true and complete, to the best of my knowledge.

Signature of Applicant Date

Witness Date

Interview Scheduled for (Date) (Time) Position

Interview Scheduled for (Date) (Time) Position

Interview Scheduled for (Date) (Time) Position

Interview Scheduled for (Date) (Time) Position