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Employment Application

Personal Information
Name*
Last
First Name*
First
Middle Name
Middle
Email*
Address*
Stree, PO Box
City*
City
State*
State
Zip*
Zip
Home Phone*
Business Phone
Have you ever been known by any other name?*
- Yes
- No
If yes, specify:
Social Security Number:
Driver's License Number:*
State:*
Date Expires:*
MM
DD
YYYY
Employment Desired
Type of position desired:*
Shift preferred:*
- Full-Time
- Part-Time
- Pool
- Permanent
- Temporary
Hours/shift preferred:*
- Days
- Evenings
- Nights
- Weekends
- No Preference
Date You Can Start*
MM
DD
YYYY
Salary Desired
Please describe any special qualifications you have for this position:
Referred by:
Have You Worked Here Before?*
- Yes
- No
If yes, when?
Where?
Background
Have you been dismissed or asked to resign from any employment?*
- Yes
- No
If yes, please explain including dates, places, and reasons:
Did any dismissal or requested resignation involve allegations of client abuse?*
- Yes
- No
If yes, please explain including dates, places, and reasons:
Have you ever been convicted of a misdemeanor or felony? (Conviction will not necessarily disqualify you from employment.)*
- Yes
- No
If yes, please explain including dates, places, and reasons:
Have you ever been the subject of proceedings to suspend or revoke any professional license or certification?*
- Yes
- No
If yes, please explain including dates, places, and reasons:
Have you ever been “excluded” from participation in any State or Federal Health Care Program by the Office of Inspector General/U.S. Department of Health Services?*
- Yes
- No
If yes, please explain including dates, places, and reasons:
Have you ever been convicted of any traffic violations?*
- Yes
- No
If yes, please explain including dates, places, and reasons:
Have you served in the Armed Forces?*
- Yes
- No
Branch of Service:
Rank:
Dates of Service:
From:
MM
DD
YYYY
Dates of Service: end-date
To:
MM
DD
YYYY
Type of Discharge:
Education
High School
Name of High School Attended
From
Month/Year
To
Month/Year
Credit Hours Received
Please enter a number from 0 to 999.
Degree or Diploma Received
Major Subjects
Trade School/Other
Name of Trade/Technical/Other School Attended
From
Month/Year
To
Month/Year
Credit Hours Received
Please enter a number from 0 to 999.
Degree or Diploma Received
Major Subjects
College
Name of College/University Attended
From
Month/Year
To
Month/Year
Credit Hours Received
Please enter a number from 0 to 999.
Degree or Diploma Received
Major Subjects
Graduate School
Name of Graduate School Attended
From
Month/Year
To
Month/Year
Credit Hours Received
Please enter a number from 0 to 999.
Degree or Diploma Received
Major Subjects
Professional Licences and Certifications
License/Certificate Number
Field or Specialty
Agency and State Issued By
Date of Expiration
MM
DD
YYYY
License/Certificate Number
Field or Specialty
Agency and State Issued By
Date of Expiration
MM
DD
YYYY
License/Certificate Number
Field or Specialty
Agency and State Issued By
Date of Expiration
MM
DD
YYYY
Employment History
Employer
Supervisor
Phone
From
Month/Year
To
Month/Year
Salary
Position
Reason for Leaving?
Employer
Name of Previous Employer
Supervisor
Phone
From
Month/Year
To
Month/Year
Salary
Position
Reason for Leaving?
Employer
Name of Previous Employer
Supervisor
Phone
From
Month/Year
To
Month/Year
Salary
Position
Reason for Leaving?
Employer
Name of Previous Employer
Supervisor
Phone
From
Month/Year
To
Month/Year
Salary
Position
Reason for Leaving?
Employer
Name of Previous Employer
Supervisor
Phone
From
Month/Year
To
Month/Year
Salary
Position
Reason for Leaving?
References
Reference 1*
Name of Reference
Address
Phone*
Years Acquainted*
Relationship*
Reference 2*
Name of Reference
Address
Phone*
Years Acquainted*
Please enter a number from 0 to 99.
Relationship*
Reference 3*
Name of Reference
Address
Phone*
Years Acquainted*
Please enter a number from 0 to 99.
Relationship*
Send Application:
ARIZONA HEALTH CARE CONTRACT MANAGEMENT SERVICES, INC. ("AHCCMS"), is an Equal Opportunity Employer and selects employees regardless of race, color, religion, sex, national origin, age, disability, or other protected groups under Local, State or Federal Equal Opportunity Laws.

1. I understand and agree that any material misrepresentation or omission of fact in my application will render this application void and may result in refusal to employ me or, if hired, termination of my employment.

2. I authorize AHCCMS to make a thorough investigation of my entire work history, to verify all data given in my application for employment, related documents, or oral interviews, and to contact my former employers, references, consumer credit reporting agencies, and any other persons. I recognize and acknowledge that any such information, including without limitation background information and consumer credit reports, may be the basis for declining the employment applied for or, if hired, for terminating the employment. I request and authorize all persons so contacted to furnish the information so requested and, in consideration for so doing, hereby release any persons furnishing or receiving such information from all liability which might arise out of the communication so made or the information so furnished.

3. I agree that, if given a conditional offer of employment, I will provide, and authorize any physician or hospital to release, any information which may be necessary to determining my ability to perform the duties of the job for which I have been offered employment.

4. I agree to take a medical examination by a qualified physician at the discretion of AHCCMS, after a conditional offer of employment has been made by AHCCMS.

5. I understand and agree that any employment offered pursuant to this application will be at-will, terminable by either party at any time with or without reason, with or without notice, and with or without procedural formality or progressive discipline. I understand and agree that no representation, written or oral, express or implied, including without limitation those contained in any employment manuals or handbooks that may be distributed to me during the course of my employment, shall form a contract between me and AHCCMS so as to alter the at-will character of my employment. I further understand and agree that no person at AHCCMS, other than the President, has any authority to make any promise or representation to alter the at-will character of my employment.

6. I understand and agree that, if offered employment hereunder, such employment shall be subject to the reasonable rules and regulations of AHCCMS as issued and changed from time to time.

7. I understand and agree that AHCCMS may at times require me to work overtime, work on holidays, change the hours and/or days I am scheduled to work, or require me to work a schedule other than that for which I was originally hired, and I accept these as conditions of my continuing employment.

8. I understand and agree that AHCCMS may change my job title, assigned duties, wages, benefits, place of employment, and/or other conditions of employment at any time, and I accept these as conditions of my continuing employment.

9. I understand and agree that a condition of my employment shall be to maintain a valid Arizona Drivers License and clearance as an approved driver by the AHCCMS insurance carrier, if my job description requires driving to conduct AHCCMS business.

10. I understand and agree that this is an application for employment, and that no employment contract is offered or implied.

I have read, understand, and agree to the above conditions.
Signature:*
Date*
MM
DD
YYYY
THIS APPLICATION WILL BE KEPT IN OUR ACTIVE FILE FOR THIRTY DAYS. YOU MUST REACTIVATE YOUR APPLICATION AFTER THAT TIME BY REAPPLYING IN PERSON.
ARIZONA HEALTH CARE CONTRACT MANAGEMENT SERVICES, INC. A Human Services Management Corporation

As an individual interested in employment with Arizona Health Care Contract Management Services, Inc. (AHCCMS), you should know that we are a private, for-profit agency that provides behavioral health services to adults who are seriously mentally ill or have developmental disabilities. Throughout its history, AHCCMS has demonstrated an ability to develop and operate unique and innovative programs designed to serve the hard to place individuals with multiple problems and/or disabilities; its mission is to provide those programs in an ethical, conscientious, and cost-efficient manner. AHCCMS supports adherence to the principles of normalization; is committed to promoting the integrity, self-reliance and well-being of each client; and works to ensure the protection of the clients’ rights while treating them with respect, dignity and compassion.

Employment with AHCCMS is “at will” which means that either you or AHCCMS may terminate the employment relationship with or without reason at any time. An employee’s job responsibilities, and any written job description, may also be changed at any time. As an employee, you are expected to be prepared to work the days and shifts assigned by your supervisor. The conditions of employment are subject to the laws and policies of federal, state and regulatory agencies, as well as to the standards set by this Company.

On the first day of New Employee Orientation, you will be asked to provide:

1. Proper identification to prove your ability to meet the age requirements specified by the State Regulatory Agencies (mm. 21 years of age for Department of Economic Security programs, and for Office of Behavioral Health Licensure programs).

2. Proof of your ability to work legally in the United States (Social Security card, Passport, Certificate of Naturalization, Alien Registration card, etc.).

3. Proof of Education: mm. G.E.D. (Graduate Equivalency Diploma).

4. A current, valid State of Arizona Driver’s License and a current (39 month) Motor Vehicle Report for individuals hired in a position with client care responsibilities.

In addition, your completed employment application should indicate your ability to meet the requirements of the posted job description. If you are unable to provide verification that you meet these requirements, you may not accept a position with AHCCMS.

The following items may also affect your employment:

Automobile Insurance: Because of contractual regulatory obligations, staff working in AHCCMS programs which do not have a company vehicle on site may be required to use their personal automobiles to conduct company business. Employees using their personal vehicle must carry a minimum of $15,000 per person/$30,000 per occurrence for Bodily Injury Liability and $10,000 per occurrence for Property Damage Liability. In addition, AHCCMS must be named on your Certificate of Insurance. If your position requires use of your personal vehicle, you must provide a Certificate of Insurance issued to AHCCMS within two weeks of your date of hire and/or before you use your personal vehicle for company business.

AHCCMS provides reimbursement for travel related to official company business. Personal vehicles must be in safe working order and have operable seat belts, adequate air conditioning and heating.

Background Investigations and Fingerprinting: AHCCMS is mandated by licensing regulations to conduct background investigations and to submit the fingerprints of all individuals who work in a DD Program. Previous employment will be verified and character references are required. An inability or refusal to provide references/employment history provides a basis for declining or terminating employment of any individual. In order to insure the safety of our clients, fellow staff and visitors, AHCCMS also completes complete background investigations (which may include fingerprinting) for all potential employees for non DD Programs, provided the potential employee has properly authorized the background check/criminal records check.

Eligibility for Benefits: All full-time employees are eligible for medical, dental and life insurance benefits the first of the month following 90 days of employment. Employees share in the cost of these benefits at a rate dependant upon the plan selected. Available benefit packages are reviewed during orientation.

Physical Examinations and TB Screens: Potential employees who have been conditionally hired to work

directly with clients on a regular basis must undergo a medical examination or provide documentation of an examination completed prior to employment beginning to verify that the potential employee if free of any and all disease that would pose a significant health and safety risk and that cannot be eliminated or reduced by reasonable accommodations. TB screens must be performed annually. AHCCMS provides for these examinations through Concentra Medical Centers at no cost to the employee/potential employee unless the employee fails to follow through on instructions provided by the examiners.

I have read and understand the responsibility of employment as indicated above.
Signature of Applicant:*
Date*
MM
DD
YYYY

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