Federation of Families of

Northeast Florida

01/02/13

Application for Employment

Mental Health America is an Equal Opportunity Employer committed to excellence through diversity. Employment offers are made on the basis of qualifications, and without regard to race, sex, religion, nationality, ethnicity, disability, age, veteran status, or sexual orientation.

PLEASE TYPE OR PRINT Position Applying For:

Name (Last, First, Middle):

Other names under which you have attended school or been employed:

Street Address:

City, State & Zip:

Social Security Number:

Home Phone:

Work Phone:

Cell Phone:

Are you eligible to work in the United States?

Yes No

Are you 18 years of age or older?

Yes No

If NO, what is your current age?

Have you ever been employed by Mental Health America

Yes No

If YES, dates of employment & reason for leaving:

Are you related to any current company employee?

Yes No

If YES, their name & their relationship to you?

Driver’s License information : State of issuance:

license #: Expiration date:

If required for position, do you have a valid professional license (nursing, etc.)? Yes No N/A

If YES, State of issuance:

license #: Expiration date:

How did you learn about this employment opportunity? Check all that apply: Ad in newspaper

Job Bulletin (Posting) /Walk-in Website Non-Profit Center Ad by Professional Organization

Referral by employee Referral by friend/colleague Other: