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Personal Info

Name
Email
Telephone
Alt. Telephone

Address Information

Address 1
Address 2
City
State
Zip Code

Position Information

Position Requested
Position Type

Detailed Information

Emergency Contact
Emergency Contact Relationship
Emergency Telephone
Are You A US Citizen?
Have You Lived Outside KY In The Last 12 Months?
If Yes, Which State
Have You Ever Been Convicted of Law Violation(s)?
If Yes, Please Explain
List Friends or Relatives Employed By A
Community MH/MR Center
Will You Only Accept Appointments In Certain Locations?
If Yes, List Locations

Education & Training

High School Diploma or GED?
Highest Grade Completed
Did You Attend College?
If Yes, Years of College Attended
If Yes, Name of College and Location
List Your Degree and Major/Minor
List Honors / Unique Skills
List Subjects Taken Related to
The Position You Prefer

Employment History

Previous Employer (1)
Immediate Supervisor
Company Address
Company Telephone
Your Title / Position
Starting Salary
Ending Salary
Employment Start Date (Month / Year)
Employment End Date (Month / Year)
Decribe Your Duties
May We Contact This Employer?


Previous Employer (2)
Immediate Supervisor
Company Address
Company Telephone
Your Title / Position
Starting Salary
Ending Salary
Employment Start Date (Month / Year)
Employment End Date (Month / Year)
Decribe Your Duties
May We Contact This Employer?


Previous Employer (3)
Immediate Supervisor
Company Address
Company Telephone
Your Title / Position
Starting Salary
Ending Salary
Employment Start Date (Month / Year)
Employment End Date (Month / Year)
Decribe Your Duties
May We Contact This Employer?

References (No Relatives, Please)


Reference (1)
Reference Phone
Reference Address
Reference Occupation
Years Known


Reference (2)
Reference Phone
Reference Address
Reference Occupation
Years Known

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Certification

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Available Start Date

By submitting this online application, you agree to the following certification:
BY SUBMITTING THIS APPLICATION, I HEREBY CERTIFY THAT ALL ENTRIES ON THIS APPLICATION AND ALL ATTACHMENTS ARE TRUE AND COMPLETE AND I AGREE AND UNDERSTAND THAT ANY FALSIFICATION OF INFORMATION HEREIN, REGARDLESS OF TIME OF DISCOVERY, MAY CAUSE FORFEITURE ON MY PART ON ANY EMPLOYMENT IN THE AGENCY. I UNDERSTAND THAT ALL INFORMATION ON THIS APPLICATION IS SUBJECT TO VERIFICATION AND I CONSENT TO REFERENCES, FORMER EMPLOYERS AND EDUCATIONAL INSTITUTIONS LISTED BEING CONTACTED REGARDING INFORMATION RECEIVED FROM SUCH CONTACTS. THE AGENCY EXECUTIVE DIRECTOR MAY DISSEMINATE INFORMATION CONTAINED ON THIS APPLICATION TO OTHER AGENCIES, NONGOVERNMENTAL ORGANIZATIONS, OR SYSTEMS ON A NEED-TO-KNOW BASIS FOR GOOD CAUSE SHOWN AS DETERMINED. I ALSO CONSENT TO A CRIMINAL RECORDS CHECK TO BE COMPLETED BY KENTUCKY STATE POLICE AT SUCH TIME THAT I MAY BECOME EMPLOYED.


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