• 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.


 


 

EMPLOYMENT EXPERIENCE

Please list the names of your present or previous employers in chronological order with present or most recent employer listed first. Be sure to account for all periods of time. If self-employed, give firm name and supply business references.

Job 1

Dates of Employment:

Job 2

Dates of Employment:

Job 3

Dates of Employment:

Job 4

Dates of Employment:

 


 

Yes No

 


 

EDUCATION:

Please describe your educational background

 

High School


Yes No

College / University


Yes No

Graduate / Professional School


Yes No

Trade School


Yes No

Other


Yes No

 


 

BUSINESS AND PROFESSIONAL REFERENCES

Please list three professional references of individuals who are not related to you.

Reference #1:

Reference #2:

Reference #3:

 


 

PERSONAL REFERENCES

Please list three people who know you well.

Reference #1:

Reference #2:

Reference #3:

 


 

GENERAL INFORMATION

Yes No
Yes No
Yes No
Yes No

6. Days/Hours available to work

Full-time  Part-time  Shift Work  Temporary  Per Diem
Yes No
Yes No
Yes No

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

Yes No

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.

 


 

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.


Yes | No

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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