Application

Application For Employment

McLeod Addictive Disease Center, Inc. is an equal employment opportunity employer and does not discriminate in recruiting , hiring, promoting, compensating or other employment terms based upon race, color, religion, creed, national origin, citizenship, sex, age, disability or veteran status. All information requested in this application will be used in a nondiscriminatory manner

Position Applied for:
NAME:
Social Security Number:
ADDRESS:
Phone Number:
State/Driver's License Number:
Email Address:
Are you 18 years of age or older?	Yes No
If hired, can you provide written evidence that you are authorized to work in the United States?	Yes No
Have you worked at the McLeod Center before?	Yes No
Do you have relatives currently employed by the McLeod Center?	Yes No
If yes, give name:
When may a McLeod Center representative contact your current employer regarding your qualifications?	anytime no time immediately prior to employment offer
Have you ever been convicted of a crime?	Yes No
(if yes, give date, place and disposition of case)
Have you ever served in the Armed Forces of the United States?	Yes No
Dates of service and Highest Rank
Name of School
Did you graduate	Yes No
Type of Degree/Major
PROFESSIONAL REGISTRATIONS OR LICENSES WHICH YOU NOW HOLD
Employment History (beginning with most recent):
Company
Address
From
To
Title
Salary
Duties
	Full Time Part Time
Reason for Leaving
Company Phone
Employment History 2
Company
Address
From
To
Title
Salary
Duties
	Full Time Part Time
Reason For Leaving
Company Phone
Employment History 3
Company
Address
From
To
Title
Salary
Duties
	Full Time Part Time
Reason for Leaving
Company Phone Number
	UNDERSTAND THIS APPLICATION, ANY OTHER WRITTEN OR ORAL COMMUNICATION, OR SUBSEQUENT EMPLOYMENT DOES NOT CREATE A CONTRACT OF EMPLOYMENT NOR GUARANTEE EMPLOYMENT FOR ANY DEFINITE PERIOD OF TIME. IF EMPLOYED, I UNDERSTAND THAT I HAVE BEEN HIRED AT THE WILL OF McLEOD ADDICTIVE DISEASE CENTER, INC. BOTH McLEOD ADDICTIVE DISEASE CENTER, INC. AND ITS EMPLOYEES HAVE THE RIGHT TO TERMINATE THE EMPLOYMENT RELATIONSHIP WITH OR WITHOUT CAUSE AT ANY TIME. NO COMMUNICATION OR PRACTICE LIMITS THE REASONS OR PROCEDURES FOR TERMINATION OR MODIFICATION OF THE EMPLOYMENT RELATIONSHIP. I authorize McLeod Addictive Disease Center, Inc. to conduct a complete police record check and driving record check. I understand that if hired, I am required by the Immigration Reform and Control Act of 1986 to provide proof of authorization to be employed in the United States. Failure to provide proof will prohibit or terminate employment. I authorize and request any and all previous employers to release to McLeod Addictive Disease Center, Inc. any information regarding my previous employment including but not limited to my performance, attendance record, reason for separation or any other information requested relative to employment. I certify that all information provided on this application is true and complete. I understand that any false information, omission, or misrepresentation may disqualify me from consideration for employment or will be grounds for immediate termination of employment if discovered at a later date. I acknowledge that I have read, understand, and by my signature, consent to each of the preceding statements.
Signature/Name of Applicant:
Date
	The following section of information is optional: VOLUNTARY SELF-IDENTIFICATION The information requested below is used by McLeod Center only to maintain records required of employers doing business with the federal government. YOU DO NOT HAVE TO ANSWER THESE QUESTIONS TO BE CONSIDERED FOR EMPLOYMENT WITH MCLEOD CENTER. If you do choose to answer these questions, any information supplied by you on this voluntary self-identification form will not affect your employment opportunities with McLeod Center, which is an equal employment opportunity employer. If you do not wish to answer these questions, scroll to the end of the application form now and click the button to submit your application.
Date of Application:
Job Applied For:
Race/Ethnicity (Put a check for one or more):	American Indian or Alaska Native Asian Native Hawaiian or other Pacific islander Black or African-American White Hispanic or Latino (White race only) Hispanic or Latino (All other races)
Sex:	Male Female I do not wish to disclose this information