jobapp

Job Application Form

Please complete this accurately, giving as many details as possible about your skills and experience related to this position. Thank you.

Position

Position Applied For

How did you hear about us

Explain

Personal Information

First Name

Last Name

Middle Initial

Mailing Address

City

State

ZIP Code

Email

Phone Number

Are you 18 years of age or older?

Yes No

Do you have a valid driver's license?

Yes No

Drivers License Number

State

Have you had any accidents in the last 5 years?

Yes No

If yes give dates/details

Moving violations in the last 5 years?

Yes No

If yes give dates/details

Check the type of employment you are seeking

Full Time Part Time Either

Date available for work

Do you have any relatives employed by MRSI?

Yes No

If yes, please specify individual(s) and your relationship

Are you aware of any potential conflicts of interest that may exist if employed by MRSI?

Yes No

If yes, please specify

Have you previously been employed by MRSI

Yes No

If yes, please give dates of employment

If you have ever been employed or attended school under other names, list name(s) and dates of use

Have you ever been decertified under Chapter 45, Section 30 of the Department of Health's Medicaid Rules?

Yes No

Have you ever been charged or convicted of any offense in a court of law other than minor traffic violations?

Yes No

Have you ever been charged or convicted of any offense against person or family?

Yes No

Crimes List

Do you appear on the WY Department of Family Services (DFS) Central Registry as "substantiated"?

Yes No

If you answered "yes" to any of the 3 previous questions, give dates, details and penalties for each occurrence.

Background checks are required for all employees who may have unsupervised access to minors or adults with disabilities or acquired brain injury. Individuals who are listed on the DFS Central Registry or convicted of crimes against person or family are not eligible for employment with Mountain Regional Services, Inc. in this capacity.

I hereby authorize personnel of Mountain Regional Services, Inc., to conduct a reference check and background investigation into my work history, training, and education. The purpose of this inquiry is to seek job-related information which will be used to determine by qualifications and suitability for employment with Mountain Regional Services, Inc.

This will be kept in strict confidence and will be available only to agency personnel who are involved in the hiring decision. I further understand information disclosed will not be made available to me. A copy of this document is also acceptable to release information. This will release from any liability all individuals and organizations who provided information to Mountain Regional Services, Inc. in good faith and without malice concerning my competence, character, ethics, and other qualifications.

I have read the above statement and agree

Yes

Do you have a high school diploma or GED certificate?

Yes No

Name of High School/Location

College or Vocational School

Dates (from - to)

Degree Earned

Date of Degree

College or Vocational School

Dates (from - to)

Degree Earned

Date of Degree

College or Vocational School

Dates (from - to)

Degree Earned

Date of Degree

Please check skills and special training

Please specify any other skills and training below

WORK HISTORY: List jobs in reverse order starting with your present or last job. Include any job-related military service assignments and volunteer activities. This section must be accurate and complete.

Employer

Address

From

To

Hours per week

Your title

Supervisor

Phone

Number and type of employees you supervised if any

Reason for leaving

Duties

Employer

Address

From

To

Hours per week

Your title

Supervisor

Phone

Number and type of employees you supervised if any

Reason for leaving

Duties

Employer

Address

From

To

Hours per week

Your title

Supervisor

Phone

Number and type of employees you supervised if any

Reason for leaving

Duties

***NOTICE: SUCCESSFUL APPLICANTS WILL BE REQUIRED TO SHOW PROOF THAT THEY ARE ELIGIBLE TO WORK IN THE UNITED STATES UNDER U.S. LAW, AND PASS A PRE-EMPLOYMENT DRUG SCREEN, AND MEET OTHER PRE-EMPLOYMENT REQUIREMENTS.*** I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an “at will” nature. This means that the employee may resign at any time, and the employer may discharge the employee at anytime with or without cause. It is further understood that this “at will” employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization. I certify that all information contained on this application is true and complete to the best of my knowledge and belief. I understand that any misrepresentations or falsifications may result in removal from employment consideration or dismissal.

I give MRSI permission to verify any job-related information given in connection with this application.

Yes