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Placement Application (Employment, Volunteers, Students, Contractors) Thank you for your interest in Metrocare Services,

Placement Application

(Employment, Volunteers, Students, Contractors)

Application (Employment, Volunteers, Students, Contractors) Thank you for your interest in Metrocare Services, north

Thank you for your interest in Metrocare Services, north Texas' leading nonprofit dedicated to helping people with mental illness, developmental disabilities, and severe emotional problems live healthier lives.

and severe emotional problems live healthier lives. Please see directions on page 4 on how to

Please see directions on page 4 on how to submit your application to Human Resources.

PERSONAL DATA

To express an interest in a position with our Center please complete this application. Applications are required on all persons who are hired by the Center. Failure to provide sufficient, truthful (and verifiable) information is grounds for the application to be rejected and not considered for an employment opportunity. If employment has commenced it is ground for disciplinary action up to and including termination of employment.

Last Name

First Name

Middle Name:

Email:

"Nick" Name:

Address:

Unit #:

   

Zip Code:

Tele 1:

Tele 2:

List all other names used (include school, employment):

 
                                               

How did you hear about this position:

   

Metrocare Website

Monster

 

Y! / Hot Jobs

Morning News

 
         

School / University

 

Prof Assoc

 

Friend

Star Telegram

 
         

Employee / Prof Org /Other:

                                               

I

I

have lived outside the state of Texas within the last twenty-four (24) months.

             

have lived, worked, and/or attended school outside the state of Texas since the age of majority (18).

             

List other states, countries you have lived:

   
                                               

I

have been convicted of a Felony or Class A misdemeanor and/or currently on deferred adjudication for a felony or Class A.

   

List Felony, Class A misdemeanors and/or current deferred adjudications and details below:

                     
   

A conviction of a Felony, Class A misdemeanor, or deferred adjudication will not necessarily disqualify you from employment with our Center. Each situation must be evaluated separately - and completely. Failure to disclose may result in disqualification from employment.

   

EMPLOYMENT DESIRED

                                         

1st Choice

2nd Choice

3rd Choice

                                               

Sal Req:

       

Day Shift

 

Evenings

   

Late Shift

 

Weekends

   
                                       
               

Full Time

 

Part Time

   

As Needed

 

Temporary

 
               

Volunteer

 

Student / Fellow / Practicum / Intern / Extern

   

072110

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072110

             

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Last Name

First Name

         

CREDENTIALS

Check all that apply

                                 

Transcripts (records) must be submitted to verify credentials.

                         

Diploma/GED

LCDC

 

LBSW

 

NP / APN

                     

AA/AS

LPC-i

 

LMSW

 

PHYS ASST

 

CERTIFICATIONS (Boards, Advanced, Speciality

)

BA/BS/BSW

LPC / LPC-S

LCSW

 

MD / DO

 

Specialty 1:

                         

MA/MS/MSW

PhD, PsyD

LMFT

 

Rx AUTHOR

                     

Spanish

American Sign

     

Vietnamese

 

Specialty 2:

                                             

Name of School Attended:

Major :

Check if you graduated

                                           

Name of School 2 Attended:

Major :

Check if you graduated

                                           

Name of School 3 Attended:

Major :

Check if you graduated

WORK EXPERIENCE - last 5 years; most recent first (Relevant volunteer activity can be listed below as well):

Organization Name

Start Date

End Date

Position Title

Start Pay

End Pay

Job Duties

Reason for leaving:

Supervisor Name

Telephone

 

Check if we can contact

         

Organization Name

Start Date

End Date

Position Title

Start Pay

End Pay

Job Duties

Reason for leaving:

Supervisor Name

Telephone

 

Check if we can contact

         

Organization Name

Start Date

End Date

Position Title

Start Pay

End Pay

Job Duties

Reason for leaving:

Supervisor Name

Telephone

 

Check if we can contact

         
                                             

List other employment:

072110

Metrocare Services is required by law to run routine background checks on all final applicants for employment, contracts, internships and volunteer positions. By signing below, I certify that the information given by me in this application for placement with Metrocare Services is true, correct, and complete. If selected for employment, contract or placement, I acknowledge the following:

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Client Abuse/Neglect Affidavit:

I certify that I have not received a confirmation by the Department of Family & Protective Services nor any other investigator with respect to any allegation of abuse, neglect, or exploitation naming me as a perpetrator. Should I be notified of an allegation or finding, I will notify Metrocare Human Resources and Quality Management departments within 24 business hours.

Employment-At-Will & Placement At-Will:

I understand that I am free to resign at any time, with or without cause and without prior notice, and Metrocare reserves the same right to terminate my employment or placement at any time, with or without cause and without prior notice, except as required by law. Any signed contractual agreement will supersede the at-will clause contained herein.

Motor Vehicle Report:

I understand that for positions, which require driving, I must be at least 18 years of age, have a valid Texas Driver's License and a good driving record. I further understand that my record will be checked for insurance purposes and if I am not insurable, I may be denied employment, placement and/or terminated if already employed.

Pre-employment Controlled Substances Screening:

I understand that I may be required to submit to a pre-employment/placement drug test that screens for illegal drugs and controlled substances; remain free of illegal drugs, alcohol and abusive levels of prescription drugs at work; and agree to the terms and conditions of random and for-cause testing for these substances. I understand failure to comply may result in immediate termination of the relationship with Metrocare Services.

Fair Credit Reporting Act:

As required by the Fair Credit Reporting Act, an investigative consumer report may be requested solely for employment purposes. If I am denied employment or placement, either wholly or partly, because of the information contained in a consumer report, a disclosure will be made to me of the name and address of the Consumer Reporting agency making such a report.

Background Investigations:

I hereby authorize Metrocare Services to investigate my past and current employment, education, criminal history, including but not limited to clearinghouse databases to include TDHS Employee Misconduct Registry, the TDHS Nurse Aide Registry, and the Department of Public Safety. If I am denied employment or placement, either wholly or partly, because of the information contained in a background report, a disclosure will be made to me of the information that affected the adverse placement or employment decision. Staff, volunteers and contractors must report convictions and pending criminal charges that are listed as bars to employment in the Texas Administrative Code to Human Resources in writing within 30 calendar days of arrest or within 10 calendar days of a court-ordered summons to appear, whichever is earliest.

I hereby authorize former employers and other persons with knowledge of my background, education or experience to release any and all

information to Metrocare Services or its designee. I understand any information collected during such investigation will be confidential and

I will not be given access to the information except in deference to the law and when written request is ma.

I certify that the statements in this application are true and complete.

application to be rejected or for discharge if I am employed by Metrocare Services.

I understand any false statement may be sufficient ground for my

This form must be submitted on all individuals named as a party to a contract with Metrocare or the proprietor (or official) of any business providing service on behalf of Metrocare Services.

I attest the information provided herein is true and accurate:

Type your full legal name is the space to the right:

Date of Birth:

Last 3 digits of Social Security #:

Last 4 of Driver's Lic #:

Driver's Lic State:

INSTRUCTION FOR COMPLETING THIS APPLICATION 1.) Complete all relevant spaces on the form. Page 4

INSTRUCTION FOR COMPLETING THIS APPLICATION

1.) Complete all relevant spaces on the form.

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2.) You must save this form as described below. Any unsaved data will not be sent:

Select "FILE," then "SAVE AS," title the file your last name and first name (example: "Smith Susan"). Send the file to CAREERS@MetrocareServices.org (make sure to attach the completed application).

3.) You may attach a resume to your emailed application; however all persons placed at Metrocare must submit an application.

4.) Applications are routed to hiring (placement) managers weekly. Hiring managers contact qualified candidates to schedule interviews.

5.) We cannot provide status updates on applications due to the high volume of resumes and applications received.

6.) Electronic (emailed) applications remain in our files for at least 2 years.

7.) Metrocare reserves the right to test applicants for use/abuse of controlled substances.

8.) Metrocare conducts thorough criminal background checks on all persons placed in our Center.

9.) Education credentials (transcripts, diplomas) will be reviewed as part of the finalist candidate review.

10.) Professional, educational and familiar (personal) references are completed as part of the finalist candidate review. All offers of placement (employment, assignment) are conditional until acceptable reference checks are completed.

REFERENCES (Must list at least 2 professional and or educational references. A third reference can be personal.)

Ref 1 Name:

Tele #:

Email:

 

Former Employer

Educational Reference

Personal Reference

 
                         

Ref 2 Name:

Tele #:

Email:

 

Former Employer

Educational Reference

Personal Reference

 
                         

Ref 3 Name:

Tele #:

Email:

 

Former Employer

Educational Reference

Personal Reference

 

NOTICE

                       

The U.S. Equal Employment Opportunity Commission enforces federal laws prohibiting employment discrimination. These laws protect you against employment discrimination when it involves: ·Unfair treatment because of your race, color, religion, sex (including pregnancy), national origin, age (40 or older), disability or genetic information. ·Harassment by managers, coworkers, or others in your workplace, because of your race, color, religion, sex (including pregnancy), national origin, age (40 or older), disability or genetic information. Denial of a reasonable workplace accommodation that you need because of your religious beliefs or disability. Retaliation because you complained about job discrimination, or assisted with a job discrimination investigation or lawsuit.

VOLUNTARY DISCLOSURE OF INFORMATION

           

The answers to these questions are not considered part of the employment consideration process. We collect this information as part of our workforce diversity efforts in our organization. This data is also used to complete federally mandated forms. Your response to these three (3) questions is voluntary.

 

Ethnicity

   

Sex

       

Position(s) Applied for:

Current Date