EMPLOYMENT APPLICATION

EMPLOYMENT APPLICATION
Name*

First NameMiddle NameLast Name
Address*
City*
State*
Zip Code*
Email Address*
example@example.com
Home Phone Number
Cell Phone Number*
Other Area of Interest
Special Skills
Please Upload Your Current Resumé

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How did you hear about Mercy House?*
What led you to want to work with us?*
Please describe briefly how you came to know the Lord including your testimony of faith*
What is your current church affiliation and background?*
Please provide a pastoral reference:
Name*
Church*
Phone Number*
Please provide two professional and/or personal references:
Name #1*
Phone Number #1*
Email Address #1*
example@example.com
Name #2*
Phone Number #2*
Email Address #2*
example@example.com
Mercy House Ministries

Staff and Volunteer Confidentiality Statement and Agreement

All staff and volunteers who have access to personal information have responsibility by which they are bound to the client, Mercy House Ministries and all its agencies, the community and themselves. The agency's clients act in good faith, expecting that all their circumstances and personal matters will remain confidential. Thus, we are obligated both by law and by ethics to honor this trust.

Though not all inclusive, the following is presented to provide some guidelines concerning the matter of confidentiality. The "Agency" refers to Mercy House Ministries and all of its agencies. The "client" is any person who is served by Mercy House or any of its Agencies.
1. No identifying information about the Agency's clients (names, addresses, social security numbers, physical disabilities, medical information, etc) should be revealed to anyone outside the agency and only to those in the Agency to whom the information is necessary for the welfare of the client.
2. Discussing personal circumstances concerning a client, even though names, addresses or social security numbers are not revealed, is also considered a breach of confidentiality. That is, a volunteer might possibly describe in detail personal circumstances and information concerning a client for whom they have provided services, and even though the name and address is not revealed, this descriptive material may jeopardize the client's right to privacy. Thus, the discussion or description of a client's personal information or circumstances in considered detrimental to the client's right to confidentiality.
3. The fact that a case has been made public through the news media does not alter the fact that the individual still has confidentiality privileges within Mercy House and all of its agencies. Thus, in these situations, confidentiality should still be maintained.
The named participant below (volunteer and/or staff) agrees to defend, indemnify and hold harmless Mercy House for any demands, claims, lawsuits arising out of or due to the disclosure of confidential information gathered during the course of service for Mercy House. THIS INDEMNITY OBLIGATION INCLUDES INDEMNITY FOR THE NEGLIGENCE, STRICT LIABILITY, AND/OR FAULT OF MERCY HOUSE.
According to the guidelines outlined above, I blank* agree to respect and maintain the confidentiality of all information obtained during my employment or volunteer period with Mercy House Ministries.
Participant Signature*

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Date*

MonthDayYear
Mercy House Ministries
PO Box 236
Colleyville, TX 76034
Confidential
Background Check Authorization
Name*

First NameMiddle NameLast Name
Former Name(s)*
Dates Used Former Name(s)*
Current Address Since*

MonthDayYear
Date
Current Address Street*
Current Address City*
Current Address State*
Current Address Zip Code*
Previous Address #1 Since*

MonthDayYear
Date
Previous Address #1 Street*
Previous Address #1 City*
Previous Address #1 State*
Previous Address #1 Zip Code*
Previous Address #2 Since*

MonthDayYear
Date
Previous Address #2 Street*
Previous Address #2 City*
Previous Address #2 State*
Previous Address #2 Zip Code*
Social Security Number*
DOB

MonthDayYear
Date
Telephone Number*
Drivers License Number/State*
The information contained in this application is correct to the best of my knowledge. I hereby authorize Mercy House and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.

I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertainingto me, to Mercy House or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.

**Mercy House and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicants personal information, including, but not limited to, addresses, social security numbers, and dates of birth.
Signature*

Clear
Date*

MonthDayYear
Date
Notice to California, Minnesota and Oklahoma Residents: Please check the box below if you wish to receive a copy of a consumer report that is requested.

I wish to receive a copy of any Background Check Report on me that is requested.
Background Check Release Background Check run and clean

Recorded date to get updated insurance information Confidentiality Policy Volunteer Application
For Office Use Only

Background Check ReleaseBackground Check run and cleanDriver's LicenseRecorded date to get updated Insurance InformationConfidentiality PolicyVolunteer Application
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