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, 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. 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 Jackie Batte. Thank you!

Mississippi Care Center of Morton

Date

Month Day Year
Professional License

License No. Type
MS Care Center Application for Employment

Please complete the form below to apply for a position with us.
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 shown that such disability prevents performance of the work involved.
Full Name *

First Name Middle Name Last Name Maiden Name (If Applicable)
Current Address *

Street Address

Street Address Line 2

City County

Postcode Country
Phone Number (Home or Cell) *
Email Address
Social Security Number *
Date of Birth *

Month Day Year
Date
Are you 18 years or older? *

Yes No
Are you authorized to work lawfully in the United States for MS Care Center? *

Yes No
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.) *

Yes No
If you have answered YES to the above, please give further details.
Were you previously employed by MS Care Center? *

Yes No
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 Time Part Time Either/Both
Will you be available to work nights and weekends if needed? *

Yes No
Do you have a mode of transportation? *

Yes No
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 School College/Other
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 name Relationship Phone number Company/Occupation
Address
Reference 2 *

Full name Relationship Phone number Company/Occupation
Address
Reference 3 *

Full name Relationship Phone number Company/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 *

Company Supervisor Salary Job title
Company Address

Street Address

Street Address Line 2

City County

Postcode Country
Phone Number

Area Code Phone Number
Employment start date *

Month Day Year
Employment end date *

Month Day Year
Responsibilities (Describe in detail.) *
Reason for leaving *
Employment details

Company Supervisor Salary Job title
Company Address

Street Address

Street Address Line 2

City County

Postcode Country
Phone Number

Area Code Phone Number
Employment start date

Month Day Year
Employment end date

Month Day Year
Responsibilities (Describe in detail.)
Reason for leaving
Employment details

Company Supervisor Salary Job title
Company Address

Street Address

Street Address Line 2

City County

Postcode Country
Phone Number

Area Code Phone Number
Employment start date

Month Day Year
Employment end date

Month Day Year
Responsibilities (Describe in detail.)
Reason for leaving
Applicant's comments relative to above employment:
By checking the "I agree" below, 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, and references 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. *

I agree
Should be Empty:

MS Care Center Application for Employment