Employment Application

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.

GENERAL INFORMATION

1. Have you ever used another name? Yes No

2. Is any additional information relative to name changes, use of an assumed name, or nickname necessary to enable a check on your work and educational record? Yes No

a. If yes to either of the above, please explain:

3. Have you ever worked for the Mental Health Association of the Southern Tier, Inc. before? Yes No

If yes, please give date

and position

4. Do you have friends and/or relatives working for the Mental Health Association of the Southern Tier, Inc.? Yes No

If yes, name(s) and relationship(s):

6. Days/Hours available to work

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

7. Are you available to work? Full-time Part-time Shift Work Temporary Per Diem

8. If hired, would you have a reliable means of transportation to and from work? Yes No

10. Are you at least 18 years old? Yes No

Note: If under 18, hire is subject to verification that you are of minimum legal age.

11. If hired, can you present evidence of your identity and legal right to work in this country? Yes No

12. Are you able to perform the essential job functions of the job for which you are applying with or without reasonable accommodation?
Yes No

Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for qualified applicants/employees to perform essential job functions.

You may attach resume:

Accepted files: PDF, JPG/JPEG and PNG. File size 5 MB maximum limit.

APPLICANT STATEMENT AND AGREEMENT

Please read and initial each paragraph below. If there is anything that you do not understand, please ask.

I hereby authorize the Mental Health Association of the Southern Tier to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorize the prior employers and references I have listed to disclose to the Mental Health Association of the Southern Tier any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the Mental Health Association of the Southern Tier, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

In the event of my employment with the Mental Health Association of the Southern Tier, I understand that I am required to comply with all rules and regulations of the Mental Health Association of the Southern Tier.

If hired, I understand and agree that my employment with the Mental Health Association of the Southern Tier is at-will, and that neither I, nor the Mental Health Association of the Southern Tier is required to continue the employment relationship for any specific term. I further understand that the Mental Health Association of the Southern Tier or I may terminate the employment relationship at any time, with or without cause, and with or without notice. I understand that the at-will status of my employment cannot be amended, modified, or altered in any way by any oral modifications.

I understand that safety of employees is extremely important to the Mental Health Association of the Southern Tier and that the Mental Health Association of the Southern Tier is committed to ensuring a safe working environment. I understand that I, and every employee, have a responsibility to prevent accidents and injuries by observing all safety procedures and guidelines and following the directions of my supervisor. I understand and agree to comply with federal, state, and local regulations related to on-the-job safety and health.

I hereby certify that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission or misstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery.

I understand that if I am selected for hire, it will be necessary for me to provide satisfactory evidence of my identity and legal authority to work in the United States, and that federal immigration laws require me to complete an I-9 Form in this regard.

I understand that if any term, provision, or portion of this Agreement is declared void or unenforceable, it shall be severed and the remainder of this Agreement shall be enforceable.

MY SIGNATURE BELOW ATTESTS TO THE FACT THAT I HAVE READ, UNDERSTAND, AND AGREE TO ALL OF THE ABOVE TERMS.

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.

Is the applicant the submitter of this form?
Yes | No

If not, name the submitter:

Submitter phone number:

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.