Tuscola Behavioral Health Systems Application For Employment

Employment Desired:
Position Applying For*
Date You Can Start*

MonthDayYear
Date
Salary Desired*
Have you ever applied to or worked for this agency before?*

YesNo
Where?
When?
Education:
High School*
Name of High School Attended
Number of Years Attended*
Did You Graduate?*

YesNo
If No, Reason for Leaving?
College
Name & Location of College/University Attended
Number of Years Attended
Did You Graduate?

YesNo
If No, Reason for Leaving?
Other Training/Education
Name & Location
Number of Years Attended
Did you Graduate?

YesNo
If No, Reason for Leaving?

Employment:
LIST ALL FORMER AND CURRENT EMPLOYERS WITHIN THE PAST 10 YEARS WITH THE MOST RECENT EMPLOYER FIRST.
1. Current Employer
Name of Current Employer or NONE if not Employed
Address of Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beginning Date of Employment
(Month & Year)
Ending Date of Employment
(Month & Year)
Salary
Position
Reason for Leaving and/Termination or Employment?
State Each & Every Reason for Leaving and/or Termination of Employment
Name of Immediate Supervisor
Phone Number of Immediate Supervisor
2. Previous Employer
Name of Previous Employer
Address of Previous Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beginning Date of Employment
(Month & Year)
Ending Date of Employment
(Month & Year)
Salary
Position
Reason for Leaving and/or Termination of Employment?
State Each & Every Reason for Leaving and/or Termination of Employment
Name of Immediate Supervisor
Phone Number of Immediate Supervisor
3. Previous Employer
Name of Previous Employer
Address of Previous Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beginning Date of Employment
(Month & Year)
Ending Date of Employment
(Month & Year)
Salary
Position
Reason for Leaving and/or Termination of Employment?
State Each & Every Reason for Leaving and/or Termination of Employment
Name of Immediate Supervisor
Phone Number of Immediate Supervisor
4. Previous Employer
Name of Previous Employer
Address of Previous Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beginning Date of Employment
(Month & Year)
Ending Date of Employment
(Month & Year)
Salary
Position
Reason for Leaving and/or Termination of Employment?
State Each & Every Reason for Leaving and/or Termination of Employment
Name of Immediate Supervisor
Phone Number of Immediate Supervisor
5. Previous Employer
Name of Previous Employer
Address of Previous Employer

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Beginning Date of Employment
(Month & Year)
Ending Date of Employment
(Month & Year)
Salary
Position
Reason for Leaving and/or Termination of Employment?
State Each & Every Reason for Leaving and/or Termination of Employment
Name of Immediate Supervisor
Phone Number of Immediate Supervisor
PLEASE PROVIDE ANY ADDITIONAL EMPLOYERS WITHIN THE PAST 10 YEARS
Include Employer Name - Address - Beginning Date - End Date - Reason for Leaving/Termination - Supervisor Name & Phone Number.
PLEASE BE SURE YOU HAVE NOT OMITTED ANY EMPLOYER REGARDLESS OF DURATION AND NATURE. PLEASE ALSO ACCOUNT FOR ALL GAPS BETWEEN JOBS.

References:
List three persons not related to you, whom you have known at least one year.
Reference 1*
Name of Reference
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Reference 2*
Name of Reference
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Reference 3*
Name of Reference
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
I authorize the references and employers listed above to provide you any and all information concerning my previous employment and any pertinent information they may have, and release you and all parties from any liability for any damages that may result from furnishing same to you. I waive any written notice of release of such information to the Agency.
Signature*
Upload Resume (Optional)

Browse Files

Cancelof
Date*

MonthDayYear
DateHourMinutesAM/PM Option

DISCLOSURE

READ CAREFULLY BEFORE SIGNING
1) I authorize TBHS to make whatever inquiries it may deem necessary in connection with my application for employment. As part of such inquiries, TBHS has my permission to contact persons who may have information relating to my suitability for employment and to secure consumer reports (including investigative consumer reports).

2) I authorize and instruct any person or agency contacted to participate or conduct inquiries at its request, to compile information, and to furnish any information obtained as a result of such inquiries whether or not such information is part of their records. I further authorize TBHS in its sole discretion, to furnish copies of this authorization and my application to any person(s) and/or consumer reporting agency(ies) in connection with the above purposes. I agree to release you and all parties from any liability for any damages that may result from furnishing such information.

Information contained in reports obtained by TBHS in accordance with the above authorization may include information pertaining to your character, general reputation, police record, personal characteristics, and mode of living. You have the right to request that TBHS completely and accurately disclose to you the nature and scope of all investigations requested. Such a request must be made in writing to the personnel department within a reasonable period of time after your application for employment is received. If employment is denied on the basis of information contained in a credit report, TBHS will advise you of its decision and provide the name and address of the credit reporting agency that made the report.

3) I certify that the information in this application is complete and correct to the best of my knowledge and understand that any falsification, misrepresentation, or omission of this information is grounds for a rejection of this Application or dismissal of any employment if I am hired.

4) I authorize TBHS to release any information requested by any of my prospective or subsequent employers without any obligation to give me written notice of such disclosure and, in consideration of its efforts to provide information, hereby release TBHS and its agents from any liability whatsoever as a result of any such inquiries and disclosures.

5) If employed, I understand that if I am or become a qualified individual with a disability in need of an accommodation in order to perform the essential functions of my job, I must notify the Chief Executive Officer in writing as soon as the need is known to me.

6) In consideration of my employment, I agree to conform to the rules and regulations of the Agency, and I agree that my employment can be terminated at any time with or without cause and with or without notice at the option of either TBHS or myself. I understand that no officer or representative of TBHS has the authority to enter into an agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing, except the Chief Executive Officer of the Company, and any such agreement must be made in a signed writing, directed to me personally. I further acknowledge that no one has made any representations or statements contrary to TBHS’ at-will policy to me, either orally or in writing, and I acknowledge and understand that no one has the authority to make such representations or statements to the contrary in the future.

7) In further consideration of TBHS’ review of my application and possible subsequent employment, I agree that any claim or lawsuit arising out of my employment with or my application for employment with TBHS or any of its subsidiaries must be filed no more than six (6) months after the date of the employment action that is the subject of the claim or lawsuit. While I understand that the statute of limitations for claims arising out of any employment action may be longer than six (6) months, I agree to be bound by the six (6) month period of limitations set forth herein, and I WAIVE ANY STATUTE OF LIMITATIONS TO THE CONTRARY. Should a court determine in some future lawsuit that this provision allows any unreasonably short period of time to commence a lawsuit, the court shall enforce this provision as far as possible and shall declare the lawsuit barred unless it was brought within the minimal reasonable time within which the suit should have been commenced.

8) I acknowledge that my employment may be subject to Public Act 29 of 2006 which requires me to fingerprinting and FBI background check.

I HEREBY ACKNOWLEDGE THAT I HAVE READ, I UNDERSTAND, AND I AGREE TO THE TERMS OF EACH OF THE ABOVE EIGHT (8) INDIVIDUAL STATEMENTS.
Signature*
Date*

MonthDayYear
DateHourMinutesAM/PM Option
Please verify that you are human*
Should be Empty:

Tuscola Behavioral Health Systems Application For Employment:

Personal Information:

Employment Desired:

Education:

Employment:

References:

DRIVER'S LICENSE INFORMATION

DISCLOSURE