Applications are available at the main office.Located at 425 5th Ave NW Attalla, AL 35954 For inquiries regarding employment and employment verifications, Click Me!Application For Employment Position(s) Applied ForDate Date Format: MM slash DD slash YYYY Name First Last PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Personal References (No Relatives or Former Employees)Name First Last PhoneEmail Name First Last PhoneEmail Have You Ever Worked for This Organization?YesNoMilitary Service?YesNoDate Entered: Date Format: MM slash DD slash YYYY Date Discharged: Date Format: MM slash DD slash YYYY Can You Provide Proof That You Are Eligible To Work In The United States?YesNoAre You Available To Work:Full TimePart TimeShift WorkOver-TimeAre You on Lay-off and Subject to Recall?YesNoCan You Travel If The Job Requires It?YesNoHave You Ever Been Convicted Of A Felony?YesNo(Conviction does not automatically disqualify applicant)If Yes, Give Full ExplanationDo You Have a Valid Driver's License?YesNoLicense NumberEducationPhysician License NumberMedicare/Medicaid NumberOther State License NumbersPsychologist, MSW, Counselor, Nurse, LPN, Pharmacist License NumberState State / Province / Region Eligible For License Date Format: MM slash DD slash YYYY High SchoolYear CompletedGraduatedYesNoCollege Or UniversityYear CompletedGraduatedYesNoWhat Was Your Major Field Of Study?Employment History (Last three employers)Employer 1 Company Name Job Title Years Employed Phone Number Supervisor Employer 2 Company Name Job Title Years Employed Phone Number Supervisor Employer 3 Company Name Job Title Years Employed Phone Number Supervisor Are You Presently Employed?YesNoMay we Contact Present Employer?YesNoWhen Could You Begin Work? Date Format: MM slash DD slash YYYY Terms: UNDERSTAND AND AGREE by Submitting1. The information given in this application is given of my own free will and accord and is true and correct to the best of my knowledge and belief. I understand that my responses to all questions on this application and during the entire application process are being relied upon by CED Mental Health in making its hiring decision. Any material misrepresentation or deliberate omission of requested information in my application may be justification for refusal of, or if employed, termination from employment. 2. An incomplete application will not be considered. 3. This is my express permission for CED Mental Health to contact prior employers to obtain any and all information related to my past work performance. It is my understanding that CED Mental Health will make a thorough investigation of my work and personal history and may verify all data given in my application for employment, related papers or oral interviews. 4. My employment may be terminated by CED Mental Health at any time without liability for wages or salary except such as may have been earned at the date of such termination. 5. Although management makes every effort to accommodate individual preferences, business needs may at times make the following conditions mandatory: overtime, shift work, a rotating work schedule or a work schedule other than Monday through Friday. 6. I understand that if offered employment, my employment may be contingent upon the results of a physical examination at the request of CED Mental Health. I consent to such an examination and to the release of the information from the examination to CED Mental Health. I also consent to submit to periodic physical examinations or blood tests as an employee of CED Mental Health. 7. All job applicants of CED Mental Health undergo testing for the presence of illegal drugs as a condition of employment. Any applicant with a confirmed positive test result will be denied employment. CED Mental Health will not discriminate against applicants for employment because of a past history of drug abuse. Therefore, individuals who have failed a re-employment test may initiate another inquiry with CED Mental Health after a period of no less than six months, but must present themselves drug-free. I further understand that this is an application for employment and that no employment contract is being offered. I understand that if I am employed, such employment is for an indefinite period of time and that CED Mental Health can change wages, benefits and conditions at any time. 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