Employment Application

Contact Information

1. First Name
2. Middle Name
3. Last Name
4. Address
5. City
6. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
7. Zip
8. Phone
9. May we contact you via text? Please Select Yes No
10. Email

---

11. Position applied for (1) Choose an open position. Administrative Assistant Bachelors Level Internship/Practicum - Care Coordinator Chief Program Officer Community Integration Activities Coordinator Crisis Response Staff Masters Level Practicum Student Outreach Worker Practicum/Internship – Social Work (Graduate) – Psychotherapy/Micro-Level Psychotherapist Registered Nurse
12. Position applied for (2) Select One (Optional) Administrative Assistant Bachelors Level Internship/Practicum - Care Coordinator Chief Program Officer Community Integration Activities Coordinator Crisis Response Staff Masters Level Practicum Student Outreach Worker Practicum/Internship – Social Work (Graduate) – Psychotherapy/Micro-Level Psychotherapist Registered Nurse
13. Date Available
14. Have you filed an application or been interviewed before by Plains Area Mental Health Center? Please Select Yes No
If yes, which position(s)?
15. Have you ever been employed by Plains Area Mental Health Center? Please Select Yes No
Employed Start Date
Employed End Date
Employed Position
Reason for Leaving

---

16. Are you legally eligible for employment in this country? Proof of U.S. citizenship/immigration status will be required. Please Select Yes No
17. What salary/hourly rate are you seeking?
18. Are you on layoff and subject to recall? Please Select Yes No
19. Will you relocate if the job requires it? Please Select Yes No
20. Will you travel if the job requires it? Please Select Yes No
21. Will you work overtime if required? Please Select Yes No
22. Have you ever been bonded? Please Select Yes No
23. Do you have any mental or physical condition that would affect your ability to perform the position(s) for which you are applying? Please Select Yes No
24. Have you ever been denied membership or participation or renewal thereof or been subject to disciplinary action by any professional society or managed care organization, including any HMO, PPO, IPA, PA or other provider network? Please Select Yes No
25. Has your participation with Medicare or Medicaid ever been the subject of any sanction, suspension or termination? Please Select Yes No

    ---

26. Do you have any record of founded child or dependant abuse? Please Select Yes No
If yes, please explain.
27. Have you been convicted of a felony? Please Select Yes No
If yes, please explain.
28. Are you using illegal drugs or other substances that may impair your employment? Please Select Yes No
If yes, please explain.

Education

High School

29. Name and Location
30. Did you Graduate? Please Select Yes No No, but received GED

College or Trade School

31. Name and Location
32. Did you Graduate? Please Select Yes No
33. Major/Subject

College or Graduate School

34. Name and Location
35. Did you Graduate? Please Select Yes No
36. Major/Subject

Employment History

List employment from the past 10 years, starting with your most recent job. Account for any time period that you were unemployed by stating the nature of your activities. Additional jobs and details may be included in your uploaded resume.

Employer 1

37. Employer Name
38. Job Title
39. Address
40. City
41. State Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
42. Zip
43. Phone
44. Start Date
45. End Date
46. Current/Ending Pay
47. Supervisor Name
48. Work Performed
49. Reason For Leaving
50. Can we contact current employer? Please Select Yes No
Add Employer

Employer 2

Employer Name

Job Title

Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Phone

Start Date

End Date

Current/Ending Pay

Supervisor Name

Work Performed

Reason For Leaving Add Employer

Employer 3

Employer Name

Job Title

Address

City

State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

Phone

Start Date

End Date

Current/Ending Pay

Supervisor

Work Performed

Reason For Leaving

Application Uploads

51. Resume
    only PDF files are allowed
52. Cover Letter
    only PDF files are allowed
53. Other Attachment
    only PDF files are allowed

---

References

Please list three personal references, other than prior employers or relatives, whom we can contact.

Reference 1

54. Name
55. Phone
56. How long have you known this reference?
57. Occupation

Reference 2

58. Name
59. Phone
60. How long have you known this reference?
61. Occupation

Reference 3

62. Name
63. Phone
64. How long have you known this reference?
65. Occupation

Additional Information

66. List any accomplishments, publications, awards or other information about you that you would like us to consider.

    Job Description

67. Have you read the job description? Please Select Yes No
68. Do you understand the requirements? Please Select Yes No
69. Can you perform the requirement of this job with or without reasonable accommodations? Please Select Yes No

Driver's License

70. If the job requires, do you have the appropriate valid driver's license? N/A Yes No
Driver's License #
License Type
State of License Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Have you had any moving violations? Please Describe.

Verification of Credentials & Release

71. Full Legal Name
72. Position/Office
73. Please list all other names that you may be known by or have used such as maiden, prior marriage(s), etc.
74. Date of Birth

---

Professional Licenses/Certificates/Numbers

75. Iowa License Number
76. Type
77. Date Issued
78. Expires

Other Licenses

79. State/Number
80. Type
81. Date Issued
82. Expires

---

83. Have your license(s) ever been removed by a licensing Board or agency? Please Select Yes No
If yes, please explain.
84. Have you ever been disciplined by, or is there disciplinary action currently pending against you, with any professional licensing Board or agency? Please Select Yes No
If yes, please explain.

---

Certifications

85. Specialty
86. Certifying Board
87. Number
88. Expires

Your Signature

It is understood and agreed upon that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed. I give the employer the right to investigate all references and secure additional verification and information about me, if job related. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. I understand that no representative of the employer has the authority to make any assurances to the contrary. I authorize Plains Area Mental Health Center to release or otherwise disclose verbally or in writing information to any and all prospective employers regarding my job performance while employed by Plains Area. I understand that the information to be provided includes but is not necessarily limited to the following: position(s) held, dates of employment, reason(s) for termination and job performance. I hereby release from liability Plains Area, its employees, directors, officers and agents from any liability of any type for releasing said information including any and all claims for damages of whatever type, regardless of whether such claims are in the nature of tort claims, contract claims or otherwise. Waiver Release: I hereby give my permission to Plains Area Mental Health, Inc. to conduct an Iowa criminal history record check with the Division of Criminal Investigation (DCI). Any criminal history data concerning me that is maintained by the DCI may be released as allowed by law.
89. Signature Please type your full name to serve as an electronic signature.
90. Today's Date