MHA Job Application

Personal Information

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Are you eligible to work in the US?

Yes?

No?

Are you at least 18 years or older?

Yes?

No?

Position desired

Date you can start

Education

High School

Please list the name, location, # of years attended and degree

If you are not a high school graduate, do you have a high school equivalency diploma?

Yes?

No?

College/University

Please list the name, location, # of years attended and degree

Other including Trade Schools etc.

Please list the name, location, # of years attended and degree

Employment History

Please provide information about your three most recent employers

Employment #1

Please list employer name, address, dates of employment and job title

Job Duties

Briefly describe your job duties

Employment #2

Please list employer name, address, dates of employment and job title

Job Duties

Briefly describe your job duties

Employment #3

Please list employer name, address, dates of employment and job title

Job Duties

Briefly describe your job duties

Do you have any certifications, special skills, experience and/or training that would enhance your ability to perform the position applied for?

If yes, please describe below

Do you have any volunteer experience?

If yes, please describe below

Do you have any experience working with individuals with social, emotional, behavioral, physical and/or development disabilities?

If yes, describe below

Background Investigation

All employees and or volunteers who provide direct service will be required to undergo a criminal history background investigation including the sex offender registry in New York and fingerprint check. Failure to meet the standards for the background investigation may result in disqualification.

Additional Comments

Please Read Carefully Before Signing

I attest with my printed name below that I have given to MHA true and complete information on this application. No requested information has been concealed. If any information I have provided is untrue, or if I have concealed material information, I understand that this will constitute cause for the denial of employment or immediate dismissal.

Signature

Date

YYYY

The New York State Human Rights Law prohibits discrimination in employment because of age, race, creed, color, national origin, sex, disability, religion, marital status or criminal record. Accordingly, nothing in this application form should be viewed as expressing, directly or indirectly, any limitation, specification or discrimination as to age, race, creed, color, national origin, sex, disability, religion, marital status, criminal record, sexual orientation or affectional preference in connection with employment. MHA IS AN EQUAL OPPORTUNITY EMPLOYER.

MHA Job Application

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