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Application for Employment

South Shore Mental Health (SSMH) is an Equal Opportunity Employer. Qualified applicants are considered for positions without regard to race, color, religion, sex, national origin, age, marital status, sexual orientation, status as a disabled veteran or a Vietnam era veteran or the presence of a disability where otherwise qualified.

PLEASE COMPLETE IN FULL.

This application will be considered for a six month period; to be considered for employment after this time frame will require the filing of a new application for employment.

Position(s) Desired:

What schedule are you available to work? (check all that apply)

Full Time: Part Time: Per Diem: (shifts as needed) Temporary
Days Evenings Nights Weekends
Social Security #:
Last Name, First Name, Middle Initial:
Street Address:
City, State, ZIP:
Home Phone:
Work Phone: Check if we MAY contact you at this number
Are you under 18?:  Yes No     Are you at least 21?:  Yes No

Have you ever been employed by South Shore Mental Health? : Yes No
If Yes, when? What Position?
Have you ever filed an application with South Shore Mental Health? : Yes No
If Yes, when? What Position?

How did you hear about us?
Ad (Which Paper?)
Job Fair Friend/Relative Walk-In/Browsing Mailed Job Posting
SSMH Employee Employee Name Relationship

In case of Emergency Notify: (Name/Address) Relationship Phone
Have you ever been convicted of a felony?
YES NO
An application for employment with a sealed record on file with the commissioner of probation may anser "no record" to an inqury herein relative to prior arrest or criminal court appeance or conviction. In addition, any applicant for employment may answer "no record" with respect to any inquiry relative to prior arrests, court appeances and adjudications in all cases of delinquency or as a child in need of services which did not result in a complaint transferred to the Superior Court for criminal prosecution.

Education and Professional Information

Type of Schooling School Name and Address Major Field of Study or Degree Graduated
High School YES
NO
College or University YES
NO
Other YES
NO

Employment History

In chronological order please list the MOST RECENT/CURRENT job first. You may include any verifiable work performed on a volunteer or intern basis. This section must be completed.

LIST LAST EMPLOYER LAST. Be complete and accurate, listing job history including military service, volunteer or intern experience.

Current or Most Recent Employer    
From Month/Year To Month/Year
 
Company Name Phone:  
 
Address:    
   
Duties:    
   
Reason for leaving:    
   
Position: Starting Salary: Ending Salary:
Was this: Fulltime Part time Temp/Relief Internship:
Supervisor Name and Title:        
       
May we contact this supervisor? Yes No
Next Most Recent Employment:    
From Month/Year To Month/Year
 
Company Name Phone:  
 
Address:    
   
Duties:    
   
Reason for leaving:    
   
Position: Starting Salary: Ending Salary:
Was this: Fulltime Part time Temp/Relief Internship:
Supervisor Name and Title:        
       
Next Most Recent Employment    
From Month/Year To Month/Year
 
Company Name Phone:  
 
Address:    
   
Duties:    
   
Reason for leaving:    
   
Position: Starting Salary: Ending Salary:
Was this: Fulltime Part time Temp/Relief Internship:
Supervisor Name and Title:        
       
Next Most Recent Employment    
From Month/Year To Month/Year
 
Company Name Phone:  
 
Address:    
   
Duties:    
   
Reason for leaving:    
   
Position: Starting Salary: Ending Salary:
Was this: Fulltime Part time Temp/Relief Internship:
Supervisor Name and Title:        
       

 

Certification, Licensure and Skills Information

If you hold a current Professional Massachusetts License relevant to the position you are applying for, please note licensure type, number and expiration date:
License Type: License Number: Expiration Date

Current relevant certifications/qualifications, please list or check all that apply:
CPR Certification First Aid Certification Medicine Administration Certification
Word Processing Typing Speed w.p.m.
NVAMB Training
Other: Please List:

(Optional) Your Email Address: