MNIS Application for Employment

MNIS Application for Employment
General Information

Prospective employees will receive consideration without discrimination because of race, color, religion, sex, age, national origin, marital status, or disability. PLEASE FEEL FREE TO LET US KNOW IF YOU NEED AN ACCOMMODATION TO COMPLETE THE APPLICATION PROCESS.
Today's Date*

MonthDayYear
Date
By checking this, you state that you are 18 years of age or older:*

I am over the age of 18
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Have you ever applied for employment with us previously?*

YesNo
If yes, date of application:

MonthDayYear
Date
If yes, location of application:
Choose where you'd like to work:*
Position Desired:*
Are you interested in:*

Part-time workFull-time work
Earliest available starting date:*

MonthDayYear
Date
How did you hear about this job?*
Will you work overtime if requested?*

YesNo
Do you have a valid driver's license?*

YesNo
Employment History & References

Please give accurate, complete full-time and part-time employment record. Start with the present or most recent employer. We may contact the employers listed below unless you indicate those you do not wish for us to contact. In the event the below listed employers are contacted, all responses will remain confidential.
Company Name*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Supervisor*
Job Title & Description of Job Duties*
Approximate Starting Date *
Month & Year
Approximate End Date *
Month & Year
Approximate Starting Wage
Approximate Ending Wage
Reason for Leaving*
May we contact this employer?*

YesNo
Company Name*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Supervisor*
Job Title & Description of Job Duties*
Approximate Starting Date *
Month & Year
Approximate End Date *
Month & Year
Approximate Starting Wage
Approximate Ending Wage
Reason for Leaving*
May we contact this employer?*

YesNo
Company Name*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of Supervisor*
Job Title & Description of Job Duties*
Approximate Starting Date *
Month & Year
Approximate End Date *
Month & Year
Approximate Starting Wage
Approximate Ending Wage
Reason for Leaving*
May we contact this employer?*

YesNo
Education
College
Name & Location of School*
Course of Study*
Number of Years Completed*
Did you graduate?*

YesNo
Degree or Diploma?*

DegreeDiploma
High School
Name & Location of School*
Course of Study*
Number of Years Completed*
Did you graduate?*

YesNo
Degree or Diploma?*

DegreeDiploma
Special Training or Skills
Name & Location of School*
Course of Study*
Number of Years Completed*
Did you graduate?*

YesNo
Degree or Diploma?*

DegreeDiploma
MNIS, Inc. is an at-will employer. Should an employee ever wish to leave our employment or should we desire to sever the employment relationship, we are both free to separate at will. This means that you may terminate your employment with the agency for any reason, and likewise, the Agency may terminate your employment at any time and for any reason.

I hereby, declare the information provided by me in this Application for Employment is true, correct, and complete to the best of my knowledge. Nebraska State Law requires that applicants for this position have criminal history checks. I authorize MNIS to obtain criminal history record information from any law enforcement agency, including the FBI, and the National Sex Offender Database. Furthermore, MNIS conducts an APS/CPS Central Registry check on applicable applications. If I so choose, I may obtain a copy of the results from MNIS.

I understand that if employed, misstatement or omission of fact on the application will be considered cause for dismissal.

Have you ever been convicted or awaiting trial of any of the following:*

	Yes	No
Possession or Distribution of Child Pornography
Human Trafficking, Sex Trafficking, or Labor Trafficking
Offensives, of whatever kind or nature against a child or vulnerable adult
Abuse, neglect or exploitation of a child or vulnerable adult
Neglect, physical abuse and/or sexual abuse
Medicaid fraud, waste, or abuse crimes within past 5 years*
Abuse, neglect or exploitation of a Medicaid participant within past 5 years*
Felony Assault, domestic violence, or terroristic threats within past 5 years
Misdemeanor Assault, domestic violence, or terroristic threats within past 3 years
Felony Controlled subtance/drug use, possession or distribution related crime within past 5 years
Misdemeanor Controlled substance/drug use, possession or distribution related crime within past 3 years
Current respondent of a protection order
Driving Under the Influence, pending or convictions, within past 5 years
Driving Under the Influence, pending or convictions, within past 3 years
Misdemeanor prostitution or solicitation of prostitution within the last 3 years
Felony robbery, burglarly, or any manner of theft within past 5 years
Misdemeanor robbery, burglarly, or any manner of theft within past 3 years
Rape or sexual assault
Homicide or Manslaughter
Listed on the Sex Offender Registry
Currently awaiting trial (or are under investigation) for any sexual abuse and/or physical abuse related to children or individuals with developmental disabilities
Felony fraud within the past 5 years
Misdemeanor fraud within the past 3 years
Felony Prostitution or solicitation of prostitution within the last 5 years
Felony fraud within the past 5 years
Misdemeanor fraud within the past 3 years

If you answered "yes" to any of the above, please describe in full:
Date*

MonthDayYear
Date
Signature*

Clear
For Office Use Only:
(Complete if Applicable)

___ Interview not offered (check one)

___ Removed self from consideration

___ Lacked basic qualifications for the job
For Office Use Only:
(Complete if Applicable)

___ Employment not offered (check one)

___ Others more qualified

___ No positions available
Interview date: __________________________________

Interviewer: __________________________________

Offer date: __________________________________

Hiring Authority __________________________________

Revised 6/87, 8/96, 5/97, 6/97, 7/97, 2/01, 4/04, 8/05, 1/06, 9/06, 1/07, 7/07, 11/07, 4/08, 9/08, 7/09, 9/11, 2/12, 11/16, 4/17, 1/23, 1/24
Title 404 NAC Chapter 4-04
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MNIS Application for Employment

General Information

Employment History & References

Education

College

High School

Special Training or Skills