Employment Application

We welcome your interest in joining the staff at Mercy Ridge. In order for you to be fully considered for a position with Mercy Ridge, it is necessary that you satisfactorily complete this application.

COMPLETE APPLICATION - Applications that have not been fully completed will not be accepted.

ACCURACY - If you wish to submit a resume, please attach it to the application. DO NOT REFER TO A RESUME IN RESPONSE TO ANY APPLICATION QUESTION. All questions must be answered on the application itself.

CRIMINAL BACKGROUND CHECKS - Criminal background checks are a mandatory part of our hiring process. As a part of your application for employment, you will be asked a question about convictions for crimes. If you answer this question 'yes', you will be asked to provide details. A 'yes' answer does not automatically disqualify you from employment. Failure to provide accurate information may affect your employment status.

DRUG USE AND REQUIRED PRE-EMPLOYMENT DRUG TESTING - Mercy Ridge does not hire or knowingly employ persons who use illegal drugs. Persons employed by Mercy Ridge may be subject to periodic tests for illegal drugs. By completing this application, you are agreeing that upon request, you will provide a urine specimen at the collections site designated by Mercy Ridge and to have the specimens tested at a laboratory selected by Mercy Ridge.

Mercy Ridge is an Equal Opportunity Employer (EOE) and does not discriminate in hiring or employment on the basis of race, color, sex, religion, disability, national origin, or on the basis of age. No question on this application is intended to secure information to be used for such discrimination. Proof of identity and work authorization will be required upon employment in accordance with federal regulations. This Company intends to check and hold you responsible for the accuracy of the statements you make on this application. This application will recieve consideration for six (6) months. A new application must be submitted after that time.

I was referred to Mercy Ridge by:

Application Information

Full Name:
	Last	First	M.I.	Other last names worked under

Address: Apt/Unit:

City: State: Zip Code:

Home Phone: Mobile Phone: Email Address:

Date Available: Social Security #: Desired Salary:

Position applied for: Full Time Part Time

Would you consider working any shift? Shift preference:

Are you a citizen of the United States? If no, are you authorized to work in the U.S.?

Have you ever worked for this company? If yes, when?

Have you ever been convicted of any crime?

If yes, briefly describe the nature of the crime(s), the date and legal disposition of the case.

References

Please list three professional references

Full Name:		Relationship:
Company:		Phone:
Address:

Full Name:		Relationship:
Company:		Phone:
Address:

Full Name:		Relationship:
Company:		Phone:
Address:

Education

High School:		Address:
From:	To:	Did you graduate?	Degree:

College:		Address:
From:	To:	Did you graduate?	Degree:

Other:		Address:
From:	To:	Did you graduate?	Degree:

Professional Licenses/Certifications

Type:		State Issued:
Date Issued:	Expires:	Number:

Type:		State Issued:
Date Issued:	Expires:	Number:

Type:		State Issued:
Date Issued:	Expires:	Number:

Please list any job-related training courses (give title and year) and or job-related skills (other languages, computer software/hardware, tools, equipment, typing speed, etc.) and job-related certificates (current only) for the position applied for.

Military Service

Branch: From: To: Rank at discharge:

Type of discharge:

If other than honorable, explain:

Work History

Include all of your employment experience in the last 7 years, listing the most recent position first. Provide your complete employment history even if you attach a resume. If you had more than one position with the same employer, list each position separately. If more space is needed, use the same format on another piece of paper. Please explain gaps of more than six months in employment on a separate piece of paper.

Company: Immediate supervisor:

Address:

Phone: Dates: From: To: Type of business:

Your title: Starting Salary: Ending Salary:

Major responsibilities:

Reason for leaving: If this is your current employer, may we contact them?

Company: Immediate supervisor:

Address:

Phone: Dates: From: To: Type of business:

Your title: Starting Salary: Ending Salary:

Major responsibilities:

Reason for leaving: If this is your current employer, may we contact them?

Company: Immediate supervisor:

Address:

Phone: Dates: From: To: Type of business:

Your title: Starting Salary: Ending Salary:

Major responsibilities:

Reason for leaving: If this is your current employer, may we contact them?

Company: Immediate supervisor:

Address:

Phone: Dates: From: To: Type of business:

Your title: Starting Salary: Ending Salary:

Major responsibilities:

Reason for leaving: If this is your current employer, may we contact them?

Affidavit and Pre-Employment Inquiry Release

By submitting I certify that all information given on this application and any accompanying documents is true, complete and correct to the best of my knowledge and belief and is made in good faith.

In connection with my employment with Mercy Ridge, I understand that investigative background inquiries will be conducted, including Criminal, Driving, Schools and other reports. These reports will include information regarding my character, work habits, performance experience along with reasons for termination from previous employers. Further, I understand that information from various Federal, State, and other agencies which maintain records concerning my past activities relating to my Driving, Criminal, Civil and other experiences, as well as claims involving me in the files of insurance companies will be requested.

I authorize all schools which I attended and all previous employers to furnish to Mercy Ridge or their agent, my record, reason for leaving and all information they may have concerning me, and hereby release them and Mercy Ridge from all liability for any damage.

By submitting this application. I authorize the Company to make investigations and indicate my awareness that false statements or failures to disclose certain information may be sufficient to disqualify me for employment, or if employed. may result in my dismissal.

I understand that proof of identity and authorization will be required upon employment in accordance with federal regulations. In the event of my employment by Mercy Ridge, I agree to abide by all present and subsequently issued rules of Mercy Ridge.

I understand that my employment is at will and that either party is free to terminate the employment relationship at any time without cause. Neither the acceptance of this application nor the subsequent entry into any type of employment relationship, either in the position applied for or any other position. and regardless of the contents of employee handbooks, personnel manuals. benefit plans, policy statements and the like as they may exist from time to time. or other Company practices, shall serve to create an actual or implied contract of employment. or to confer any right to remain an employee of Mercy Ridge, or otherwise change in any respect the employment-at-will relationship between it and the undersigned. and that relationship cannot be altered except by a written instrument signed by the Executive Director of the Company.

I understand that any claim or lawsuit relating to my service with Mercy Ridge must be filed no more than six (6) month after the date of the employment action that is subject of the claim or lawsuit. I waive any statute of limitations to the contrary.

UNDER MARYLAND LAW, AN EMPLOYER MAY NOT REQUIRE OR DEMAND, AS A CONDITION OF EMPLOYMENT, PROSPECTIVE EMPLOYMENT, OR CONTRACTED EMPLOYMENT, THAT AN INDIVIDUAL SUBMIT TO OR TAKE A LIE DETECTOR OR SIMILAR TEST. ANY EMPLOYER WHO VIOLATES THIS LAW IS GUILTY OF A MISDEMEANOR AND IS SUBJECT TO A FINE NOT EXCEEDING $100.

Please e-mail resume's to hr@mercyridge.com