Online Pre-Employment Questionnaire
Applicants with disabilities who desire accommodation in completing the pre-employment questionnaire are invited to discuss their needs with Personnel Coordinator.

Basic Information
First Name Middle: Last
Street City State Zip:
Position Applying For: Social Security No. **Provide at time of Interview**
Locations willing to work: Willing to Relocate?
Are You a US Citizen? Are you legally authorized to work in the United States?
Phone:    
Cell Phone:    

Education

 
Name
Address
Graduate?
Degree
Major
High School
Jr. College
College/Univ
College/Univ
If space is not sufficient, please list remaining institutions attended, with Name, Address and Major in the Comments Section.
If offered a position, it is each applicant's responsibility to provide the necessary transcripts to support educational requirements above high school graduation.

Professional Licenses and/or Certifications
License
No.
Expiration Date
Original Issue Date
Current Renewal Date

Other Questions

1. Has your professional license ever been revoked? Suspended?
If Yes, please Explain
2. Have you ever been excluded from participation in Medicare, Medicaid, and/or any other federal funded program?
If Yes, please Explain
3. Have you, since age 18, been convicted of a misdemeanor or felony, other than minor traffic violations? (NOTE: Each conviction will be judged in relation to time, seriousness and circumstances and will not necessarily bar you from employment).
If Yes, please explain:
4. Have you ever been counseled or disciplined for inappropriate behavior toward others, failure to follow safety rules or procedures, or failure to follow instruction?
5. Have you ever been terminated or ask to resign? (if "Yes", please explain)
6. Have you previously been employed by NWAMHC?
If yes, please provide dates of employment and your full name during this period
 Date From To
  Full Name
7. Are you related to anyone in our employment? If Yes, give name:

Work Experience
Beginning with your present or most recent employment, list in REVERSE ORDER your periods of employment. If space is not sufficient, attach a list of other remaining jobs.

1.          
Employer Type of Business Phone:
Address Position Held Salary
Start Date End Date Supervisor`
Supervisor name Supervisor Title May we contact for reference?
Current Employer Yes No
Summarize the nature of the work performed & job responsibilities:
Reason for leaving
2.          
Employer Type of Business Phone:
Address Position Held Salary
Start Date End Date Supervisor`
Supervisor name Supervisor Title May we contact for reference?
Current Employer Yes No
Summarize the nature of the work performed & job responsibilities:
Reason for leaving

3.          
Employer Type of Business Phone:
Address Position Held Salary
Start Date End Date Supervisor`
Supervisor name Supervisor Title May we contact for reference?
Current Employer Yes No
Summarize the nature of the work performed & job responsibilities:
Reason for leaving


IMPORTANT: READ CAREFULLY BEFORE AGREEING
Please agree or disagree to each of the following statements.

Initial Here
  

NWAMHC does not discriminate in hiring or employment on the basis of race, color, sex, religion, national origin, disability, or age.
I authorize NWAMHC to investigate thoroughly my previous work history, work record, educational credentials, and personal references, and to conduct a criminal background check. I will hold no person reliable for giving or receiving information in this investigation.

I understand that all applicants must provide documents proving U.S. citizenship or eligibility to work legally in the U.S. Proof of identity and work authorization will be required upon employment in accordance with federal regulations.
I understand that all applicants of NWAMHC may require changes in the work environment and assigned schedules, including but not limited to overtime, holidays, weekend work, and rotating shifts. In the event of employment by NWAMHC, I agree to adhere to such changes and abide by all present and subsequently issued policies and procedures of NWAMHC.
I understand that this application must be filled out in its entirety before applicants will be considered for employment at NWAMHC.
 
CERTIFICATION: I certify that all statement on or attached to this application are true and correct to the best of my knowledge. I understand that any false statement will cause me to be refused employment or terminated if employment was based on false information which the employer determined to have been made knowingly and the falsity is discovered after I am employed. I also understand that a criminal background check will be requested for records of my convictions, if any. I also understand that refusal to submit/cooperate with a blood or urine test after an accident as set forth in DOT drug testing policy, will forfeit rights to recover worker's compensation benefits. I understand that if I am employed that I will be employed at will and that I or the employer may terminate the employment at any time for any lawful reason.
Do you agree? Yes No
 

Authorization to Obtain Consumer Report Information

I understand that, as a part of the employment selection process, Northwest Alabama Mental Health Center routinely obtains information on applicants for employment. I hereby expressly authorize Northwest Alabama Mental Health Center to obtain consumer information regarding me, such as my credit worthiness, ability, character, reputation, personal characteristics and/or mode of living.
I understand that such information may be used in making a decision regarding my employment and that if I am denied a position because of information obtained from a consumer-reporting agency, I will be notified and provided the sources of such information.
Do you agree? Yes No
 

NWAMHC is an Equal Opportunity Employer. All applicants are considered for employment without regard to race, color, sex, age, disability, religion, nation origin or military veteran's status.

Please allow the server a few moments to process your application to the appropriate department. You may check in with our office in 48 hours to make sure your application was received. Please give the full name that you used on the application.