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For Services
24 hours a day:
(334) 742-2877
or (800) 815-0630
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Employment Application
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FOR
OFFICE USE ONLY
Date
Letter
Reference
Check by
Interview
for
App
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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
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Name
and location of business, correspondence, or
vocational
school attended
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FROM
Mo.
Yr.
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TO
Mo.
Yr.
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Did
you
Graduate?
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Area
of
Study
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Degree
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Name
and location of Colleges and Universities attended
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FROM
Mo.
Yr.
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TO
Mo.
Yr.
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Did
you
Graduate?
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G.P.A.
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Maximum
obtainable
G.P.A.
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Field(s)
of Study
Major(s)
Minors(s)
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Degree
and
Date
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Graduate/Professional/Medical
School
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Residency/Internship/Fellowship
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List
professional certificates or licenses and state where issued
Is
your license current and in good standing? Yes No
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Educational
subjects and/or training related to the duties of the position for
which you are applying.
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Sem.
Hrs.
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Qtr.
Hrs.
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Office/business
machines operated
Software
packages operated
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Professional
Memberships
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Word
processing preference
Typing
Speed/WPM (net)
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Employment
applications are active for six months.
FORM 14-42 (07/01)
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
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WORK
HISTORY
Beginning with your PRESENT or most recent employment, list
in REVERSE ORDER periods of employment. Each time you changed jobs or
your title changed should be listed as a separate period. Describe in
detail your specific duties as they relate to the duties of the position
for which you are applying. Attach additional sheets if necessary.
1. Current or Last Employer
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Your Official Job Title
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Address
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Type of Business
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City State
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Telephone
( )
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From
Mo.
Yr.
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To
Mo. Yr.
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If
part-time,
number
of hours
per week
|
Beginning
Salary
$ per
|
Ending
Salary
$ per
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May
we contact
employer?
[ ] Yes [ ] No
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Name of Supervisor
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Reason for Leaving
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Describe your Duties
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2. Current or Last Employer
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Your Official Job Title
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Address
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Type of Business
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City State
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Telephone
( )
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From
Mo.
Yr.
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To
Mo. Yr.
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If
part-time,
number
of hours
per week
|
Beginning
Salary
$ per
|
Ending
Salary
$ per
|
May
we contact
employer?
[ ] Yes [ ] No
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Name of Supervisor
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Reason for Leaving
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Describe your Duties
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3. Current or Last Employer
|
Your Official Job Title
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Address
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Type of Business
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City State
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Telephone
( )
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From
Mo.
Yr.
|
To
Mo. Yr.
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If
part-time,
number
of hours
per week
|
Beginning
Salary
$ per
|
Ending
Salary
$ per
|
May
we contact
employer?
[ ] Yes [ ] No
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Name of Supervisor
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Reason for Leaving
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Describe your Duties
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4. Current or Last Employer
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Your Official Job Title
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Address
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Type of Business
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City State
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Telephone
( )
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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
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Name of Supervisor
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Reason for Leaving
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Describe your Duties
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5. Other Employers
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From
Mo. Yr.
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To
Mo. Yr.
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Reason for Leaving
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Describe in detail other
clinical experience not included
previously (including educational training such as clinical
practica or internships)
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REFERENCES
List three persons, unrelated to you, who can give
information about you (preferably two persons who have supervised
your work).
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Name
Occupation Phone
Street Address City State Zip Code
How do you know this person?
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Name
Occupation Phone
Street Address City State Zip Code
How do you know this person?
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Name
Occupation Phone
Street
Address City State Zip Code
How do you know this person?
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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
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