Suncoast Employee Application

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

The position you are applying for: *

Have you previously worked at Suncoast Mental Health Center, Inc.? *

YesNo

Citizenship: Suncoast Mental Health Center, Inc. hires only U.S. citizens and lawfully authorized alien workers. If a conditional offer of employment is made, you will be required to provide identification and proof of citizenship or authorization to work in the U.S. Are you eligible to work in the U.S.?*

YesNo

Criminal Record Information Have you ever been arrested ?*

YesNo

Have you ever been convicted ___YES ___NO of a crime other than minor traffic offenses? An arrested/conviction will not necessarily automatically disqualify you for employment. Rather, such factors as age and date, seriousness and nature of the crime, and rehabilitation will be considered.*

YesNo

If yes, please provide details (nature of offense, dates, and locations for all arrests/convictions). Use additional paper if necessary.

Driver’s License: Do you have a VALID Florida driver’s license?*

YesNo

I am aware that any omissions, falsifications, misstatements, or misrepresentations above may disqualify me for employment consideration and, if I am hired, may be grounds for termination at a later date. I understand that any information I give may be investigated as allowed by law. I consent to the release of information about my ability, employment history, and personnel staff for employment purposes. This consent shall continue to be effective during my employment if I am hired. I certify that to the best of my knowledge and belief all of the statements contained herein and on any attachments are true, correct, complete, and made in good faith.*

Education: High School Name and Location*

Did you receive a Diploma?*

YesNo

College: University or professional school (Transcripts may be requested) *

Name of School and location*

Dates of Attendance (Month/Year)*

Credit Hours Earned

Major/Minor Course Of Study

Training Completed

Additional College: University or professional school (Transcripts may be requested)

Name of School and location

Dates of Attendance (Month/Year)

Credit Hours Earned

Major/Minor Course Of Study

Training Completed

Licensure: License, Registration, or Certification

Type

Number

Expiration Date

State Licensing Agency

Knowledge/ Skills/ AbilitiesList the skills and/or abilities that you possess and believe relevant to the position you seek, such as payroll platform, accounting software, phone systems, computer skills, fluency in language(s), etc.

Describe all work experience, beginning with your current or most recent job. Include military service (indicate rank), internships, and job-related volunteer work, if applicable. All information in this section must be completed. Resumes may be attached to provide additional information.

Name and Address of Present or Last Employer

Job Title

Salary

Supervisor's Name

Phone Number

Please enter a valid phone number.

Resigned or Terminated

Start and End date of employment

Duties and Responsibilities

Reason for Leaving

Name and Address of Present or Last Employer

Job Title

Salary

Supervisor's Name

Phone Number

Please enter a valid phone number.

Resigned or Terminated

Start and End date of employment

Duties and Responsibilities

Reason for Leaving

Name and Address of Present or Last Employer

Job Title

Salary

Supervisor's Name

Phone Number

Please enter a valid phone number.

Resigned or Terminated

Start and End date of employment

Duties and Responsibilities

Reason for Leaving

Applicant Data Record

Applicants are considered for all positions, and employees are treated equally during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap. As an employer/government contractor, we comply with government regulations and affirmative action responsibilities. Solely to help us comply with government record keeping, reporting and other legal requirements, please fill out the Applicant Data Record. We appreciate your cooperation. Refusal to provide this information will not subject you to adverse treatment. This data is for periodic government reporting and will be kept in a confidential file separate from the Application for Employment.

Government agencies require periodic reports on sex, ethnicity, disability and veteran status of applicants. This data is for analysis and affirmative action only. Submission of information about a disability is voluntary.

MaleFemalePrefer not to sayOther

Check One of the Following

Hispanic or LatinoWhite (Not Hispanic or Latino)Black or African American (Not Hispanic or Latin)Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)Asian (Not Hispanic or Latino)Prefer not to sayOther

Check if any of the following are applicable

How did you hear about us?*

If a person referred you, please write first and last name below.