MS Care Center of Morton Employment Application

APPLICATION PROCESS

I. Submit application.

II. Initial interview will be performed after application is reviewed (personal references, work references, criminal background check and C.N.A. registry status). Your eligibility of employment is dependent upon verification of the information you have provided.

III. A second interview will begin the hiring process.

*Please be sure to include all phone numbers for work and personal references listed, sign the criminal background check sheet, and pre-employment drug screen. Be sure to include ALL work history. (You may include additional information on a word document if needed).

You must provide telephone numbers for work and personal references or your application will be considered incomplete. Incomplete applications will not be considered for hire.

**To check on application, please call (601) 732-6361 and speak to Merri Ezelle. Thank you!

Mississippi Care Center of Morton

MS Care Center Application for Employment

Please complete the form below to apply for a position with us.
Date

MonthDayYear
Equal Opportunity/Affirmation Action Employer

It is the policy of MSCC of Morton to assure that no person will be discriminated against, or be denied the benefit of any activity, program or employment process, in the areas of recruitment, advertising, hiring, upgrading, promotion, transfer, demotion, lay off, termination, rehiring, employment, rates of pay and/or other compensation.MSCC of Morton is an Affirmative Action/Equal Opportunity Employer and is strongly committed to all policies which will afford equal opportunity employment to all qualified persons without regard to race, color, religious creed, age, marital status, nationalorigin, ancestry, sex, sexual orientation, mental retardation, learning disability, protected veterans, present or past history of mental disorder, or physical disability including, but not limited to, blindness, unless it is shownthat such disability prevents performance of the work involved.
Full Name*

First NameMiddle NameLast NameMaiden Name (If Applicable)
Current Address*

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Phone Number (Home or Cell)*
Email Address
Are you 18 years or older?*

YesNo
Social Security Number*
Have you been convicted of a crime in the past 5 years which resulted in imprisonment? (A conviction will not necessarily disqualify you for the job applied for.)*

YesNo
If you have answered YES to the above, please give further details.

Were you previously employed by MS Care Center?*

YesNo
If Yes, when?
List any friends or relatives working here:
Is there any one employee who is responsible for you applying?
Position applying for:*
Can you work:*

Full TimePart TimeEither/Both
Will you be available to work nights and weekends if needed?*

YesNo
Who would we notify in case of any emergency? List name, address, and telephone number:*
Education

Please use this section to provide information about your previous education including the qualifications/certificates your have gained.
Type in highest level completed

Grade School and High SchoolCollege/Other
Professional License

License No.Type
Certification

Certification No. (If applicable)Type
Refrences

Please use this section to provide a list of three professional references. (Not former employers or relatives)
Reference 1*

Full nameRelationshipPhone numberCompany/Occupation
Address
Reference 2*

Full nameRelationshipPhone numberCompany/Occupation
Address
Reference 3*

Full nameRelationshipPhone numberCompany/Occupation
Address

Previous employment

Please use this section to provide information about your previous employment starting with your current or most recent job.
Employment details*

CompanySupervisorSalaryJob title
Company Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Phone Number

Area CodePhone Number
Employment start date*

MonthDayYear
Employment end date*

MonthDayYear
Responsibilities (Describe in detail.)*
Reason for leaving*
Employment details

CompanySupervisorSalaryJob title
Company Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Phone Number

Area CodePhone Number
Employment start date

MonthDayYear
Employment end date

MonthDayYear
Responsibilities (Describe in detail.)
Reason for leaving
Employment details

CompanySupervisorSalaryJob title
Company Address

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Phone Number

Area CodePhone Number
Employment start date

MonthDayYear
Employment end date

MonthDayYear
Responsibilities (Describe in detail.)
Reason for leaving
Applicant's comments relative to above employment:
I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal employments, educations, financial, or medical history and other related matters as may be necessary for an employment decision. I hereby release employers, schools or persons from all liability in responding to inquiries in connection with my application. In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in discharge.
Signature of Applicant*

Clear

P.O. Box 459 | 96 Old Highway 80 East | Morton, MS 39177 | (601) 732-6361
PERMISSION FOR BACKGROUND CHECK CRIMINAL RECORDS
I hereby give my permission for the above named facility to conduct a background screening check with the law enforcement, previous employers, and any other persons to determine my suitability in working with patients/residents of Mississippi Care Center of Morton.

I give my permission for the release of information from law enforcement files concerning any past history criminal offences with which I may have been charged or convicted.

I understand that the information will be released on any conviction, any pending charges, or any arrests, if I have been arrested two or more times.

I understand that Mississippi Care Center of Morton has the right to require this record check as a condition of employment.

I understand I will be sent a copy of any information released from your files pursuant to this permission form that I have the right to challenge that accuracy and completeness of this information.

I understand that this information will be used only for employment purposes and will not be reproduced or distributed to other persons or used for any other purposes.
Full Name*

First NameMiddle NameLast NameMaiden Name (If Applicable)
Current Address*

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Date of Birth*

MonthDayYear
Social Security Number*
Signature of Applicant*

Clear
Signature of Witness and Date*

Clear
Previous address if changed within last 5 years:

Street Address

Street Address Line 2

CityCounty

PostcodeCountry
Should be Empty:

MS Care Center Application for Employment

PERMISSION FOR BACKGROUND CHECK CRIMINAL RECORDS