Application for Employment First Name(required) Last Name(required) Address(required) Phone Number(required) Are you at Least 21?(required) Yes No Are you authorized to work in the U.S. on an unrestricted basis? Yes No Position Applied For: When can you start?(required) How did you learn of this opening? Have you worked here before?(required) Yes No Have you been told essential functions of the job or have you been shown a copy of the job description listing the essential job functions of the job?(required) Yes No Can you perform these essential functions with or without reasonable accommodation?(required) Yes No Are there any hours, shifts, or days that you cannot or will not work? What county are you willing to work in?(required) Jackson Macon Either/Both Shift Preferred: Are you willing to work overtime as required?(required) Yes No Education High School(required) Diploma GED Didn't Complete College/University: Year Graduated: Degree: Work History Most recent/Current Employer: May We Contact your current employer?(required) Yes No Name and Title of Supervisor? Address Phone Date Started Date Left Description of duties:(required) Starting/Ending Salary(required) Reason for leaving:(required) Previous Employer: May we contact them?(required) Yes No Name and Title of Supervisor: Address of business: Phone Date Started Date Left Description of Job Duties: Starting/ Ending Salary: Reason for Leaving: Previous Employer: May we contact them?(required) Yes No Name and Title of Supervisor: Address: Phone Date Started Date Ended Description of Job Duties: Reason for Leaving Applicant’s Certification and Agreement I CERTIFY THAT THE FACTS SET FORTH IN THIS APPLICATION FOR EMPLOYMENT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT IF I AM EMPLOYED, FALSE STATEMENTS, OMISSIONS, OR MISREPRESENTATIONS MAY RESULT IN MY DISMISSAL. I AUTHORIZE MCH TO MAKE AN INVESTIGATION OF ANY OF THE FACTS SET FORTH IN THIS APPLICATION, INCLUDING REFERENCES. BY SIGNING, I AUTHORIZE MCH TO CHECK REFERENCES. I UNDERSTAND THAT EMPLOYMENT AT MCH IS "AT WILL" WHICH MEANS THAT EITHER I OR MCH CAN TERMINATE THE EMPLOYMENT RELATIONSHIP AT ANY TIME, WITH OR WITHOUT PRIOR NOTICE, AND FOR ANY REASON NOT PROHIBITED BY STATUTE. ALL EMPLOYMENT IS CONTINUED ON THAT BASIS. I UNDERSTAND THAT NO SUPERVISOR, MANAGER, OR EXECUTIVE OF MCH, OTHER THAN THE EXECUTIVE DIRECTOR OR BOARD HAS ANY AUTHORITY TO ALTER THE FOREGOING. FAILURE TO SIGN WILL BE CONSIDERED AN INCOMPLETE APPLICATION AND WILL NOT BE CONSIDERED. Applicant's Certification and Agreement(required) Agree Personal Reference 1: Family Member(required) Name:(required) Daytime Phone Number:(required) Personal Reference 2: Non – Family Member(required) Name:(required) Phone:(required) Work Reference 1: Supervisor or Manager only(required) Name:(required) Daytime Phone:(required) Work Reference 2: Supervisor or Manager only(required) Name:(required) Daytime Phone:(required) Information Release Authorization I authorize all corporations, former employers, personal references, credit agencies, education institutions to release information about my background including, but not limited to information about my employment, education, and general public records history to mch. This releases the aforesaid parties from any liability and responsibility for collecting the above information. Information Release Authorization(required) Authorization for Release of Information Submit
