Employment Application

Application Date*

Personal Information

Your Name* (Last, First MI)

Social Security Number *

Address*

City*

State*

Zip*

Your Email*

Home Phone

Day or Cell Phone

Pre-Employment Requirements

Answer yes or no to all questions

Background is clear of Felonies, Misdemeanors, Domestic Violence &/or Assault and Abuse Offenses
YesNo

I am free of illegal substances and can pass a Pre-employment Drug Screen. Note: We do random drug tests.
YesNo

I have a current valid Tennessee Drivers License
YesNo

For Fleet Vehicle Insurance Eligibility: I am age 21 or older
YesNo

I have a Clear Driving Record
YesNo

I currently have or can get either a savings or checking account for required paycheck direct deposit before hired.
YesNo

I am eligible for lawful employment in this country
YesNo

Reasons I do not meet the above qualifications

Employment Desired

Position:

Date Available to Work:

Desired Hourly Wage:

I am available to work at the following work-sites:
JacksonBrownsvilleBolivar

Work Interest:
Full TimePart Time

Times Available:
AnytimeDays OnlyNights OnlyWeekends Only

Have you ever applied at MHDS any location before?
NoYes

If yes, when and where?

Did someone refer you?
NoYes

If yes, whom?

Are you related to anyone currently working for MHDS any location?

What professional or personal experiences have you had with developmentally, physically or mentally disabled adults?

Special Skills and Training (i.e.: typing, accounting, etc.)

Certifications

CERTIFICATION EXPIRATION DATE TAKEN BUT EXPIRED CERTIFICATION EXPIRATION DATE TAKEN BUT EXPIRED
CNARNLPN Taken But Expired Relias Training (Annuals) from a MRDD Provider Taken But Expired
Arc Cert (1 year)AHA Cert (2 years) Taken But Expired PCM Professional Crisis Management Taken But Expired
Arc First Aid (3 yrs)AHA First Aid (2 yrs) Taken But Expired Home Manager Certification Taken But Expired
Administration of Medication by Unlicensed Personnel (2 yrs exp.) Taken But Expired Taken But Expired

 

EDUCATION SCHOOL NAME AND LOCATION YEAR GRADUATED DEGREE
HIGH SCHOOL DiplomaGED
Arc Cert (1 year)AHA Cert (2 years) Taken But Expired PCM Professional Crisis Management
Arc First Aid (3 yrs)AHA First Aid (2 yrs) Taken But Expired Home Manager Certification
Administration of Medication by Unlicensed Personnel (2 yrs exp.) Taken But Expired

 

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