Employment Demo - The Michael Dunn Center

Date *

Personal

Name *

First

Middle

Last

Maiden Name / Other

(include all other names by which you have been known)

Preferred Name

(the name you prefer to be called)

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone: Daytime *

Phone: Evening

Phone: Work

Work Desired

Position or Type

Date Available

Preferred Status

Full Time
Part Time
Either

If part time, what hours?

Desired Shift

Preferred Days

Check each day (above) that you are WILLING to work (days with a checkmark indicate days you are willing to work)

Are you legally eligible for employment in this country?

Yes
No

Are you over 18 years of age?

Yes
No

History with MDC

Have you ever applied here before?

Yes
No

If Yes, give date

Have you ever been employed here before?

Yes
No

If Yes, give dates

From

To Date

To

Employment Status

Are you currently employed?

Yes
No

May we call you at work?

Yes
No

May we contact your current employer?

Yes
No

Are you on layoff and subject to recall?

Yes
No

Overtime Work

Will you work overtime, if asked?

Yes
No

Convictions

Have you ever been convicted of a felony?

Yes
No

Driving Data

Have you held a valid driver's license for 3 years?

Yes
No

Has your driver's license ever been revoked?

Yes
No

Will a review of your driving record reveal any citations?

Yes
No

If Yes, please explain

Driver's License Number *

(enter "No License" if you do not have a driver's license)

State of Issue *

(select "Not Applicable" if you do not have a driver's license)

Tell Us Now

Is there anything which would affect your ability to perform the job for which you are applying?

Yes
No

If Yes, please explain

Certification

I *

the undersigned applicant, certify and affirm that, to the best of my knowledge and belief; (I “have” or “have not”, as applicable) had a case of abuse, neglect, mistreatment or exploitation substantiated against me. As a condition of submitting this application and in order to verify this affirmation, I further release and authorize Michael Dunn Center, the Tennessee Department of Intellectual and Developmental Disabilities and the Bureau of TennCare to have full and complete access to any and all current or prior personnel or investigative records, from any party, person, business, entity or agency, whether governmental or non-governmental, as pertains to any allegations against me of abuse, neglect, mistreatment or exploitation and to consider this information as may be deemed appropriate. This authorization extends to providing any applicable information in personnel or investigative reports concerning my employment with this employer to my future employers who may be Providers of DIDD services.

EDUCATION, SKILLS, & PROFESSIONAL MEMBERSHIPS

High School

Years Completed

0
10
11
12

(click the highest grade level)

Diploma Received

Diploma
GED
Neither

Under what name did you attend/graduate?

School Name

School City

State

College

College Type

2 Year
4 Year

Years Completed

(click the highest year)

Degrees Received (check all that apply)

School Name

School City

State

Other

Certificates
Licenses
Nursing License

(check all that apply)

If Nursing License, License Number is:

Memberships

List any professional, trade business or civic organizations to which you belong or are associated:

1

2

3

4

5

6

REFERENCES

Job Referral

How did you find out about this job?

If referred, list referral’s name

List name and telephone number of at least three business or work references who are not related to you. If not applicable, list at least three school or personal references.

Name

Phone Number

Years Known

Name 2

Phone Number 2

Years Known 2

Name 3

Phone Number 3

Years Known 3

Name 4

Phone Number 4

Years Known 4

EMPLOYMENT HISTORY

Must include at least 5 years history of employment or other activity.
If you've only had one job during the past 5 years, please list additional jobs you may have had.
Please explain any gaps in employment history (see "Additional Information" later in this section)

Employer 1

Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates Employed:

From

To

Job Title

Starting Salary

Final Salary

Employed under what name?

Work performed

Immediate Supervisor

Supervisor Title

Reason for leaving

Employer 2

Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates Employed: From

To

Job Title

Starting Salary

Final Salary

Employed under what name?

Work performed

Immediate Supervisor

Supervisor Title

Reason for leaving

Employer 3

Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates Employed: From

To

Job Title

Starting Salary

Final Salary

Employed under what name?

Work performed

Immediate Supervisor

Supervisor Title

Reason for leaving

Employer 4

Name

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates Employed: From

To

Job Title

Starting Salary

Final Salary

Employed under what name?

Work performed

Immediate Supervisor

Supervisor Title

Reason for leaving

Additional Information

Please provide any additional information that you consider important:

UNDERSTANDINGS & PERMISSIONS

It is understood that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed.

I give the employer the right to investigate all references and to secure additional information about me, if job related.

I give permission for you to contact my former employers concerning my past job performance. I further release my former employers from any liability to me concerning their descriptions of my performance. I hereby release from liability the employer and it’s representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

I authorize Security Walls, LLC to make whatever inquiries it deems necessary in connection with my application for employment or in the course of review of any employment. I authorize all persons, schools, companies, corporations, credit bureaus, department of motor vehicles and law enforcement agencies to supply information concerning my background. I release Security Walls, LLC, Equifax, and all persons who provide information to Security Walls, LLC concerning me, harmless from all liability or any damages resulting from the inquiry and the furnishing of said information.

A photocopy of this authorization shall be deemed an original and shall be accepted as such by every person. I understand that I have the right to request a copy of any report by writing to Security Walls, LLC within 60 days. The fee for this report will be paid at my expense to Security Walls, LLC. As per the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained from a consumer reporting agency such as Security Walls, LLC.

The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

I understand it is the company’s policy not to refuse to hire a qualified individual with a disability because of this person’s need for an accommodation that would be required by the ADA.

I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice.

I understand that no representative of the employer has the authority to make any assurances to the contrary.

I understand that a criminal background check will be done before I am considered for employment. I give permission for my background to be checked.

This application will be kept on file for 6 months. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

Release Authorization

Name *

First

Middle

Last

Date *

Include Resume

Click or drag a file to this area to upload.

(only PDF or MS Word files accepted)