EMPLOYMENT

APPLICATION

All Applicant will be given Equal Consideration regardless of Race, Gender, Age, Color, National Origin, Marital or Veteran Status, Sexual Orientation, Religion, Disability or any other Legally Protected Status.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Nepotism: It is the responsibility of every employee and applicant to identify to Human Resources any potential or existing personal relationship that falls under the definitions provided in this policy. Employees who fail to disclose personal relationships covered by this policy will be subject to termination of employment. For the purposes of this policy the term “relative” shall include the following relationships: mother, father, including step-parent; spouse, including life partner or significant other living in the same household; son or daughter, including step-child or grandchild; sister or brother; mother-in-law or father-in-law; brother-in-law or sister-in-law; daughter-in-law or son-in-law; grandmother or grandfather; aunt or uncle; niece or nephew; cousin.

CORI and Fingerprint Background Checks: A Criminal Offender Record Information (CORI) will be completed on all prospective employees, subcontractors, volunteers and interns with their written consent. Once the CORI is completed and the result complies with 101CMR 15.00, a record will be created for the prospective candidate and a “Case ID #” will be assigned for the National Background Check (NBC). The candidate will be notified by Human Resources of their Case ID # and will be required to make an appointment to go to one of the MorphoTrust/IdentiGo locations to be fingerprinted within 3-5 business days of notification. The candidate will be required to pay the $45.00 fee for the fingerprint test and if hired will be reimbursed by the agency upon successful completion of initial probationary period. The results from the NBC should be available in 2-3 days of the fingerprint being done.

Pre-employment drug screening: Applicants receiving an offer of employment with CMHS, as a condition of employment, will be required to participate in pre-employment drug testing. All drug-testing information will be maintained in a confidential file. The substances that will be tested for are: Marijuana (THC), Amphetamines, Cocaine metabolite, Opiates and Phencyclidine (PCP). Testing for the presence of the metabolites of drugs will be conducted by the analysis of urine. Any applicant who tests positive will not be hired, unless they provide proof of a medical marijuana registration card for the substance that resulted in the positive test. CMHS will enter into an interactive process with applicants who test positive for marijuana with a medical marijuana registration card to determine if a reasonable accommodation would be possible or would create an undue hardship for CMHS. An applicant will be subject to the same consequences of a positive test if he/she refuses to cooperate in the testing process in such a way that prevents completion of the test. If an applicant violates the drug-free workplace policy, the offer of employment will be withdrawn.

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Personal Information (Please Print ALL Information)

 

 

 

 

 

 

 

 

Last Name

 

 

 

First Name

 

MI

 

 

 

 

 

 

 

Address

 

 

 

City

 

State

 

Zip

 

 

 

 

 

 

 

 

 

 

Telephone #

 

 

 

 

Email Address

 

 

 

 

 

 

 

 

 

 

 

 

Type of position for which your are applying

 

 

 

 

 

 

 

 

 

 

 

 

Are you available to work:

Full Time

Part Time

Please indicate shift(s):

1

2

3

 

Are you available to work weekends, rotating shifts and holidays:Yes No

Have you previously applied for a job here?

 

Yes

No. If yes, give date:

 

Have you ever been employed with us before?

 

Yes

No. If yes, give date:

 

Date available for work?

 

 

 

 

 

 

 

 

 

 

 

 

 

List any relatives in our employ: Name:

 

 

Relationship:

How did you hear about us?

 

Are you legally permitted to work in the United States? Yes

No (Documentation will be required)

Do you have a valid drivers license?

Yes

No

License#:

 

 

 

State:

 

 

 

 

 

 

 

 

 

 

 

 

 

Has your license ever been suspended or revoked:

 

Yes

 

No If yes, why?

Academic Training

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

High School:

Diploma?

Yes

No

 

GED: Yes No

Undergraduate College:

Degree?

 

Yes

No

Major:

Professional/Graduate School:

Degree?

 

Yes

No

Major:

Other (Specify):

 

 

 

 

 

 

 

 

 

 

 

 

Describe any specialized training, apprenticeship, skills and extra-curricular activities. Include job-related skills and qualifications acquired from past job or other experience, including computer skills:

Employment History (Please Print ALL Information)

IMPORTANT – List every employment whether or not it seems relevant to position applied for.

If lapse occurred between periods of employment, give dates and reason for unemployment. You may also include any verified volunteer work. We may contact the employers listed below unless you indicate those you do not want us to contact.

1.
Employer Name/Address
     
Telephone#   From   To   Job Title/Department
     
Supervisor   Start Wage   End Wage   Reason for Leaving
May we contact? Yes No
2.
Employer Name/Address
     
Telephone#   From   To   Job Title/Department
     
Supervisor   Start Wage   End Wage   Reason for Leaving
May we contact? Yes No
3.
Employer Name/Address
     
Telephone#   From   To   Job Title/Department
     
Supervisor   Start Wage   End Wage   Reason for Leaving
May we contact? Yes No

Personal References (Do not include family members or past supervisors)

Name

Address

Phone#

Years Known

Name

Address

Phone#

Years Known

Name

Address

Phone#

Years Known

Reason for Applying (Please print ALL Information)

Please tell us why you want to work in this field and/or for this agency:

Applicant’s Statement

I understand that my employment is conditional upon my providing proof of identification and authorization to work in the United States. I hereby acknowledge notification that an inquiry may be made to procure information relating to my work experience, criminal history, character, general reputation and personal characteristics. I hereby acknowledge that the results of such inquiries will have a direct impact on any decision to hire, or on my continued employment with CMHS, Inc. In connection with any inquiry which might be made, I hereby authorize all schools, persons, companies, corporations, credit bureaus and agencies, public and private, who possess information about me and/or act as custodians of any records relating to me, to release to this company or any designated representative thereof, any and all information concerning my background and personal history and release them from any liability and responsibility which might result. I indemnify CMHS, Inc. from any liability, which might result from making such inquiry.

I understand that the facilities must be staffed 24-hours/7-days per week, in order to provide necessary services to clients. I understand that work schedules are designed to meet facilities’ needs and that I may be required to work shifts other than the one for which I am applying.

I acknowledge and understand that applicants will be given equal consideration regardless of race, gender, age, color, national origin, marital or veteran status, sexual orientation, religion or disability. No question on this application is intended to secure information concerning the aforementioned. Any offer of employment may be conditioned upon the result of medical examination requested by the Employer and conducted solely for the purpose of determining whether an individual, with reasonable accommodation, is capable of performing the functions of the job.

This application will be given every consideration, but its receipt does not imply that employment will be offered. I understand further that any misrepresentation or omission of facts is sufficient cause for cancellation of this application or separation from the company if I am employed.

Additionally, I understand that nothing contained in this employment application or in the granting of an interview is intended to create an employment contract between CMHS, Inc. and myself for either employment or for the providing of any benefit. No promises regarding employment have been made to me. I understand that no manager or representative, other than the Chief Executive Officer, has any authority to enter into any agreement for employment for any specified period of time; and that any agreement with the CEO must be in writing and signed. If an employment relationship is established, I understand that I have the right to terminate my employment at any time and CMHS, Inc. retains a similar right.

I hereby acknowledge that I have read the foregoing disclosures and understand them.

 

Signature of Applicant

 

Date