Employment Application

6295 Ferris Square, Suite B
San Diego, CA 92121
Lic. #593515
An Equal Opportunity Employer

:: Please Print ::

Date:
Last Name:
First Name:
Middle Name:
Present Address:
City:
State:
Zip:
Home Phone:
Cell Phone:

:: Employment Desired ::

Position applying for:

Are you applying for: Regular full-time Regular part-time Temporary work

What days and hours are you available for work?

If applying for temporary work, during what period of time will you be available? From: to

Are you available to work on weekends? Yes No

Would you be able to work overtime, if neccessary? Yes No

If hired, on what date can you start work?

Salary desired:

:: Personal Information ::

Have you ever applied to/or worked for MHS Customer Service, Inc. before? Yes No

If yes, when?

Do you have any friends or relatives working for MHS Customer Service, Inc.? Yes No

If yes Name: Relationship:

Who referred you to apply at MHS Customer Service, Inc.?

If hired, would you have a reliable means of transportation to and from work? Yes No

Are you at least 18 years old? (if under 18, hire is subject to verification that you are of minimum legal age) Yes No

If hired, can you present evidence of your U.S. Citizenship or proof of your legal right to live and work in this country?
Yes No

Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation? Yes No

If no, describe the functions that cannot be performed:
(Note: We comply with the ADA and consider reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. Hire may be subject to passing a medical examination, and to skill and agility tests.)

Have you ever been convicted of a criminal offense (felony or serious misdemeanor)? (Convictions for marijuana-related offenses that are more than two years old need not be listed.) Yes No

If yes, state nature of the crime(s), when and where convicted and disposition of the case.
(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Are you currently employed? Yes No

If so, may we contact your current employer? Yes No

:: Education, Training and Experience ::

High School

Name:

Address: City:

State: Zip:

# of Years Completed: Did You Graduate? Yes No

Degree/Diploma:

College/University

Name:

Address: City:

State: Zip:

# of Years Completed: Did You Graduate? Yes No

Degree/Diploma:

Vocational/Business

Name:

Address: City:

State: Zip:

# of Years Completed: Did You Graduate? Yes No

Degree/Diploma:

Many of our customers (clients) do not speak English. Do you speak, write or understand any foreign languages?
Yes No

If yes, which language(s)?

Do you have any other experience, training, qualifications or skills which you feel make you especially suited for work at MHS Customer Service, Inc.?
Yes No

If so, please explain:

:: Employment History ::

List below all present and past employment starting with your most recent employer (last five years is sufficient). Account for all periods of unemployment. You must complete this section even if attaching a resume.

Name of Employer: Telephone No:

Type of Business: Your Supervisor's Name:

Address:

Date of Employment: From: To:

Weekly Pay: Starting: Ending:

Your position and duties:

Reason for leaving:

May we contact this employer for a reference? Yes No

Name of Employer: Telephone No:

Type of Business: Your Supervisor's Name:

Address:

Date of Employment: From: To:

Weekly Pay: Starting: Ending:

Your position and duties:

Reason for leaving:

May we contact this employer for a reference? Yes No

Name of Employer: Telephone No:

Type of Business: Your Supervisor's Name:

Address:

Date of Employment: From: To:

Weekly Pay: Starting: Ending:

Your position and duties:

Reason for leaving:

:: Military Service ::

Have you obtained any special skills or abilities as the result of service in the military? Yes No

If so, describe:

:: References ::

List below two persons not related to you who have knowledge of your work performance within the last three years.

First Name: Last Name: Phone #:

Address: City: State:

Zip: Occupation: # of Years Acquainted:

First Name: Last Name: Phone #:

Address: City: State:

Zip: Occupation: # of Years Acquainted:

:: Please Read Carefully, Initial Each Paragraph ::

I hereby certify that I have not knowingly withheld any information that might adversely affect my chances for employment and that the answers given by me are true and correct to the best of my knowledge. I further certify that I, the undersigned applicant, have personally completed this application. I understand that any omission ormisstatement of material fact on this application or on any document used to secure employment shall be grounds for rejection of this application or for immediate discharge if I am employed, regardless of the time elapsed before discovery. MHS is a drug free environment. All potential employees will be drug/alcohol tested prior to employment offer.

Initials:

I hereby authorize the company to thoroughly investigate my references, work record, education and other matters related to my suitability for employment and, further, authorized the references I have listed to disclose to the company any and all letters, reports and other information related to my work records, without giving me prior notice of such disclosure. In addition, I hereby release the company, my former employers and all other persons, corporations, partnerships and associations from any and all claims, demands or liabilities arising out of or in any way related to such investigation or disclosure.

Initials:

I understand that nothing contained in the application, or conveyed during any interview which may be granted or during my employment, if hired, is intended to create an employment contract between me and the company. In addition, I understand and agree that if I am employed, my employment is for no definite or determinable period and may be terminated at any time, with or without prior notice, at the option of either myself or the company, and that no promises or representations contrary to the foregoing are binding on the company unless made in writing and signed by me and the company’s designated representative.

Initials: