• 47 Broad Avenue Binghamton, NY 13904

  • Phone (607) 771-8888

  • Fax (607) 771-8892

Employment Application

Employment Application

Mental Health Association of the Southern Tier, Inc.

47 Broad Avenue, Binghamton NY 13904
Phone: (607) 771-8888
Fax: (607) 771-8892

MHAST is an equal opportunity employer and affords equal opportunity to all applicants for all positions without regard to race, color, religion, gender, national origin, age, disability, veteran status or any other status protected under local, state or federal laws.


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Days and Hours Available: (If employed, I will notify my supervisor in writing, should my availability change.)

 


 

EDUCATION:

 

Elementary-school

High-school

College

Graduate

Vocational

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EMPLOYMENT HISTORY

(Begin with current or most recent employer.) Do not exclude any employment. Include any applicable temporary employment attach another sheet if necessary. Previous salaries or wages will not be used to determine compensation at MHAST.)

Job 1

Dates of Employment:

Job 2

Dates of Employment:

Job 3

Dates of Employment:

Job 4

Dates of Employment:

 


 

PROFESSIONAL REFERENCES:

(Please list three professional references, who are not related to you and can provide professional opinions on your work performance.)

Reference #1:

Reference #2:

Reference #3:

 


 

APPLICANT ACKNOWLEDGEMENT AND AUTHORIZATION

*PLEASE READ CAREFULLY BEFORE SIGNING*

I hereby certify that all of the information provided by me in this application (or any other accompanying or required documents) is correct, accurate and complete to the best of my knowledge. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment or immediate termination of employment regardless of the timing or circumstances of discovery.

I understand that submission of an application does not guarantee employment. I further understand that, should an offer of employment be extended by MHAST (hereinafter referred to as MHAST that such employment with MHAST is at will, for no specified duration and may be terminated by either MHAST or myself at any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions, statements of MHAST or its representatives used during the employment process is deemed a contract of employment real or implied. I understand that no representative of MHAST except the Executive Director has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the Executive Director of MHAST.

In consideration for employment with MHAST, if employed, I agree to conform to the rules, regulations, policies and procedures of MHAST at all times and understand that such obedience is a condition of employment. I understand that due to the nature of MHAST business, attendance and punctuality are considered essential requirements of every job at MHAST and that poor attendance or tardiness will result in disciplinary action.

I understand that if offered a position with MHAST, I may be required to submit to a pre-employment medical examination, drug screening and background check as a condition of employment. I understand that unsatisfactory results from, refusal to cooperate with, or any attempt to affect the results of these pre-employments tests and checks will result in withdrawal of any employment offer or termination of employment if already employed.

I herby authorize any and all schools, former employers, references, courts and any others who have information about me to provide such information to MHAST and/or any of its representatives, agents or vendors and I release all parties involved from any and all liability for any and all damage that may result from providing such information.

I understand that this application is considered current for three months. If I wish to be considered for employment after this period I must fill out and submit a new application.

BY SIGNING BELOW I ACKNOWLEDGE THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ABOVE STATEMENTS.

By the applicant entering their name in the box below, they are electronically signing this application and it carries the same legal value as if it were signed by the applicant in person.


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MHAST IS PROUD TO BE AN EQUAL OPPORTUNITY EMPLOYER. ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION WITHOUT REGARD TO RACE, COLOR, RELIGION, GENDER, NATIONAL ORIGIN, AGE, DISABILITY, VETERAN STATUS OR ANY OTHER STATUS PROTECTED BY LAW.


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