Memphis Recovery Centers, Inc. Special Instructions for Pre-Employment Application Read this document in full. Initial each item indicated. Memphis Recovery Centers is concerned with hiring the most qualified employees to serve our patients. Every question must be answered, and in a responsive manner. Answers such as will discuss in interview, or refer to resume, are not acceptable. If every blank is not fully completed your application will be rejected. (Initial) Applicants are encouraged to attach letters containing additional information and/or other supporting documents. Additional explanations concerning Alcohol and Drug treatment, current recovery, or Alcohol and Drug counseling experience are especially recommended. Such information should not, however, be used in lieu of fully completing the Pre-Employment Application. (Initial) Pre-employment Drug and Alcohol Testing To minimize drug and alcohol abuse problems from the outset, drug and alcohol tests will be given to persons to whom a position is to be offered. Top candidates under consideration may also be given drug and alcohol tests. (Initials) If a test indicates unlawful drugs or unauthorized drugs in the applicant's system, the applicant will not be employed. As with all decisions to employ or not employ particular applicants, the applicant will only be told that he/she was not selected. No further information will be provided, except as required by law. (Initials) Any misrepresentation or misleading information on this pre-employment application will preclude employment here or result in dismissal if hired. Once you have submitted your application, follow-up phone calls or visits are not desired and will not be accepted. Pre-Employment Applications are kept on file for thirty days only. (Initials) We request that applicants not wear perfume or cologne. (Initials) TN law prohibits smoking in the workplace. (Initials) Memphis Recovery Centers, Inc. is an Equal Opportunity Employer. Mail your application to: Human Resources Manager Memphis Recovery Centers, Inc. 219 North Montgomery Street Memphis Tennessee 38104 Pg 1
Memphis Recovery Centers, Inc. Pre-Employment Application App # HR010408 PLEASE PRINT Position(s) applied for Date of application / / Referral Source Advertisement Employee Relative Other Name of Source (if applicable) Name last first middle Previous Names Used street city state zip Telephone Number ( ) Social Security Number - - If necessary, best time to call you at home is... : am/pm you at work?... Yes No Are you over 24?... Yes No Have you filed an application here before?... Yes No If Yes, give date...... / / Have you ever been employed here before?... Yes No If Yes, give dates...from / / To / / Are you legally eligible for employment in this country?... Yes No (Proof of U.S. Citizenship or immigration status will be required upon employment.) Date available for work...... / / Type of employment desired Full-Time Part-Time Temporary Are you on lay-off and subject to recall?... Yes No Are there times you will be unable to work?... Yes No If Yes, give times... Will you work overtime if required?... Yes No Have you ever been bonded?...... Yes No Have you ever been convicted of a felony, sex related crime, child abuse related offense or D.U.I? Yes No (Such conviction may be relevant if job related, but does not bar you from employment.) If yes Please explain Are you on parole or probation at this time?... Yes No Is your driver s license valid at this time?... Yes No Driver s license # State Expiration date / / Type Pg 2
EMPLOYMENT HISTORY List your last four employment experiences starting with the most recent. Explain any gaps in employment below. Comments, including explanations regarding gaps in employment: Pg 3
EDUCATIONAL BACKGROUND A. List last three (3) schools attended, starting with most recent. B. List number of years completed. C. Indicate degree or diploma earned if any. D. Grade Point Average or Class Rank and E. Major field of study F. Graduated: Yes/No. A. School B. Number of Years Completed C. Specify Degree/ Diploma Received (if any) D. GPA Class Rank E. Major F. Graduated Yes / No REFERENCES List name and telephone of three business/work references that are not related to you and are not previous supervisors. If not applicable, list three school or personal references that are not related to you. Name Telephone Years Known Area Code ( ) Area Code ( ) Area Code ( ) List professional, trade, business, or civic associations and any offices held. (Memberships which would reveal gender, race, religion, national origin, age, color, disability or other protected status are optional.) Organization Offices Held List Special accomplishments, publications, awards (Information which would reveal gender, race, religion, national origin, age, color, disability or other protected status is optional.) Who should be contacted in case of emergency? Relationship Name Home Phone Street address City State Zip Pg 4
Skills and Qualifications -Summarize any special training, licenses or certificates that may qualify you as being able to perform job-related functions for the position for which you are applying: Have you ever served in the military?... Yes No Service/Branch : Date entered : / / Date separated : / / Final Rank : Are you a member of a reserve organization?... Yes No Will you abide by the safety rules of the company?... Yes No Are you willing to have a physical exam and a drug screen at company expense?... Yes No Have you ever received treatment for alcohol and/or drug use?... Yes No Have you ever used any illegal drug, including marijuana, in the last two years?...... Yes No In the space below describe any special knowledge of chemical dependency treatment and Twelve Step programs. (If recovering indicate sobriety date/clean date, sponsor s name and number with his/her permission, and AA/NA/CA/ACOA etc. meetings regularly attended.) Continue on separate page if necessary. Sobriety/clean date: / / Sponsor s name and phone # (list all if you have more than one): AA/NA/CA/ACOA etc. Meetings regularly attended. List Home Group First. Pg 5
Memphis Recovery Centers, Inc. It is understood and agreed upon 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. (Initial) I give the employer the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability the employer and its representatives for seeking such information and all other persons, corporations, or organizations for furnishing such information. (Initial) 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. (Initial) 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. (Initial) This application is current for only 30 days. 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. (Initial) You must state your minimum salary requirement: $ per Hour Week Month Year Signature of Applicant X Date / / Pg 6
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