253 MANSION STREET

POUGHKEEPSIE, N.Y. 12601

845-473-2500

Application for Employment Position applying for:______

Name:______/______/______

First Middle Initial Last

Address:______/______/______/______

Street City State Zip

Home Phone:______-______-______Cell Number:______-______-______

Social Security Number ______-______-______

Institution / Years Attended / Degree Y/N
High
School/GED
College
College
Graduate
School

EDUCATION

Scholastic Honors: ______

Specialized Training or Skills:______

______

______

MILITARY SERVICE

Did you serve in the U.S. Armed Forces?
What years did you serve?
Do you have a protected veteran class? Y/N what class?
What Branch of the U.S. Military did you serve with?
Did you receive any relevant training or education while in military? Y/N
If Yes please list

RELEVANT EMPLOYMENT HISTORY:

Please completeorattach resume

Employer Address Telephone
Supervisor Your Job Title Dates of Employment
Reason For Leaving
Employer Address Telephone
Supervisor Your Job Title Dates of Employment
Reason For Leaving
Employer Address Telephone
Supervisor Your Job Title Dates of Employment
Reason For Leaving
Employer Address Telephone
Supervisor Your Job Title Dates of Employment
Reason For Leaving

We may contact the employers listed above unless otherwise requested.

DO NOT CONTACT:______

REASONS:______

The information requested below is needed for legally permissible reasons, including but not limited to national security considerations, a legitimate occupational qualification or business necessity. The Civil Rights Act of 1964 prohibits discrimination in employment because of race, color, religion, sex or national origin. Federal law also prohibits discrimination based on age, citizenship and disability.

****Please take note that MHA of Dutchess County will conduct an independent background investigation on all applicants prior to being hired.****

HAVE YOU EVER BEEN CONVICTED OF A FELONY, EXCLUDING MISDEMEANERS AND SUMMARY OFFENSES, WHICH HAS NOT BEEN ANNULLED, EXPUNGED OR SEALED BY COURT?______IF YES, DESCRIBE IN FULL.
______
CLASS OF DRIVER’S LICENSE:______EXPIRATION DATE: ______
MOTORIST I.D. # ______STATE OF ISSUANCE:______
HAVE YOU HAD ANY MOVING VIOLATIONS IN THE PAST FIVE YEARS?______
IF YES PLEASE DESCRIBE:______
______
______
IN THE PAST 5 YEARS HAVE YOU BEEN THE DRIVER FOR ANY ACCIDENTS WHERE THERE WERE INJURIES TO YOURSELF OR
OTHERS? ______
IF YES PLEASE DESCRIBE:______
______
______
HAVE YOU BEEN PROCESSED THROUGH THE NEW YORK STATE CHILD ABUSE REGISTRY BY ANY OTHER AGENCY?______
IF YES, PLEASE NAME THE AGENCY: ______PHONE______

REFERENCES

Personal Reference One

Name:______

Address:______

Street City Zip

Phone Number: ______-______-______

Personal Reference Two

Name:______

Address:______

Street City Zip

Phone Number: ______-______-______

Professional Reference One

Name:______

Company Name: ______

Phone Number: ______-______-______

Professional Reference Two

Name:______

Company Name: ______

Phone Number: ______-______-______

*****PLEASE READ CAREFULLY BEFORE SIGNING*****

Consent to obtain information relative to employment

I certify that the information in this application is true and complete. I understand and agree that any false information, misrepresentation, or concealment of fact is sufficient grounds for either refusal of employment or if hired, my immediate termination from employment by Mental Health America or Dutchess County.

I understand and agree that all information furnished in this application may be verified by Mental Health America of Dutchess County. I also understand that any employment is subject to a satisfactory check of references. I hereby authorize all individuals and organizations named or referred to in this application (except those noted) and any law enforcement organization to give Mental Health America of Dutchess County all information relative to my employment, work habits and character, and I hereby release such individuals, organizations and Mental Health America of Dutchess County from any liability for any claim or damage which may result.

I understand that giving this authorization may result in the release of information which may be negative, which I may disagree with or result in my not being hired by Mental Health America of Dutchess County. I further understand that I have no right to influence or otherwise impact Mental Health America of Dutchess County’s ability to obtain correct and factual information about me.

______

Signature Date

BACKGROUND & CRIMINAL HISTORY CHECK

CONSENT FORM

I authorize Mental Health America of Dutchess County to perform an independent investigation of my background and criminal or police records, including those maintained by both public and private organizations and all public records, for the purposes of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for employment.

Mental Health America of Dutchess County is an equal opportunity employer and does not discriminate against applicants or employees on the basis of race, color, national origin, sex, age, religion, disability or veteran status. I understand that the inquiries on this form which addresses date of birth and sex are for identification purposes only, and as such, are asked in good faith for legitimate and non-discriminatory reasons.

I release Mental Health America of Dutchess County and any person or entity which provides information pursuant to this authorization from any and all liabilities, claims or lawsuits in regard to the information obtained from any and all the above referenced sources used.

Last Name:______First Name:______Middle Initial ____

Driver’s License # ______State of Issue ______

Date of Birth: ______-______-______Social Security # ______-______-______

Maiden Name:______

List all addresses in past 7 years

Current Address:______/______/______/______/______

Street City State Zip Years

Previous Address:______/______/______/______/______

Street City State Zip Years

Previous Address:______/______/______/______/______

Street City State Zip Years

Previous Address:______/______/______/______/______

Street City State Zip Years

______

Signature Date