Job Application - Mental Health America Boone County

Personal Information

Date*

Program for which you are applying:*

B.A.S.E.
Y.S.P.P.
Growing Minds Learning Center
MHABC - general

What position from our job board are you applying for?*

B.A.S.E. Group Leader
B.A.S.E Site Leader
Y.S.P.P Lead Teacher
Growing Minds - Assistant Teacher
Other

What type of employment are you seeking?*

Available Starting Date*

Referral Source*

Name*

First Last

Birth Date*

Phone*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Have you ever been convicted of or charged with a felony or misdemeanor?*

Please explain the details in full, including dates, details of offense(s) charged, jurisdiction and disposition of case:*

Education*

List High School and Colleges attended - # of Years Attended - Year Graduated - Degree

Employment/Work Experience

Start with your present or most recent position. Include military service assignment and volunteer activities. Exclude organization names that indicate race, color, religion, sex, or national origin.

Employer #1*

Job Title #1*

Supervisor #1*

Phone #1

Address #1*

Street Address Address Line 2 City State ZIP Code

Describe Duties/Responsibilities/Accomplishments #1*

Reason for Leaving #1*

Dates of Employment #1*

Employer #2

Job Title #2

Supervisor #2

Phone #2

Address #2

Street Address Address Line 2 City State ZIP Code

Describe Duties/Responsibilities/Accomplishments #2

Reason for Leaving #2

Dates of Employment #2

Employer #3

Job Title #3

Supervisor #3

Phone #3

Address #3

Street Address Address Line 2 City State ZIP Code

Describe Duties/Responsibilities/Accomplishments #3

Reason for Leaving #3

Dates of Employment #3

Personal References

Please provide names, addresses, phone numbers, relationship and how long known for three references.

Reference #1*

First Last

Relationship to Reference #1*

How many years have you known Reference #1?*

Please enter a number from 1 to 60.

Phone for Reference #1*

Address for Reference #1*

Street Address Address Line 2 City State ZIP Code

Reference #2*

First Last

Relationship to Reference #2*

How many years have you known Reference #2?*

Please enter a number from 1 to 60.

Phone for Reference #2*

Address for Reference #2*

Street Address Address Line 2 City State ZIP Code

Reference #3

First Last

Relationship to Reference #3

How many years have you known Reference #3?

Please enter a number from 1 to 60.

Phone for Reference #3

Address for Reference #3

Street Address Address Line 2 City State ZIP Code

B.A.S.E Group Leader Questions

What do you feel makes you the ideal candidate for the group leader position at your site?*

If you are hired for the position, describe some strategies you would use to lead your team of site staff.*

List experience you possess that makes you qualified for this position.*

Special Skills or Certifications

Describe any special skills, certifications, or qualifications related to the job you are applying for:*

Consent*

I agree.

I CERTIFY that the above answers are true and complete to the best of my knowledge. I authorize Mental Health America of Boone County, Inc. to investigate any statement contained in this application, and to obtain a credit report and/or a criminal history background check on me as necessary to determine my qualifications. I understand that this application is not and is not intended to be any kind of contract or agreement. In the event of employment, I understand that any false or misleading information given in my application, correspondence, discussions or interview may result in immediate termination. I understand also, that I am required to abide by all rules, regulations and policies of Mental Health America of Boone County, Inc.

Full Legal Name*

Date*

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MHABC Job Application

Personal Information

Employment/Work Experience

Personal References

B.A.S.E Group Leader Questions

Special Skills or Certifications