Employment Application

ANCHORAGE COMMUNITY MENTAL HEALTH SERVICES, INC.
An Equal Opportunity Employer
Application for Employment

Date of Application:*
Name:*
FirstLast
Email:*
Phone:*
Address:*
Street AddressCityStateZip Code
Work/Daytime Phone:*
Please enter the job number and name of the position(s) you are applying for.
Position 1:*
Position 2:
Position 3:
Names of relatives in our employ:
Date available for work:*
May we contact you at work?*
- Yes
- No
Have you ever been employed here before?*
- Yes
- No
If you answered, 'Yes' - give date*
Have you ever been bonded?*
- Yes
- No
If you answered, 'Yes' - with whom?*
If you are under 18, can you furnish a work permit?*
- Yes
- No
Are you legally eligible for employment in this country?*
- Yes
- No
PROOF OF U.S. CITIZENSHIP OR IMMIGRATION STATUS WILL BE REQUIRED UPON EMPLOYMENT
Have you been charged with, convicted of, found not guilty by reason of insanity for, or adjudicated as delinquent for any felony or misdemeanor crime?*
- Yes
- No
If 'Yes', then please explain*
Veteran of the U.S. military service?*
- Yes
- No
If 'Yes', which branch?*
ALL HIRES REQUIRE THE EMPLOYEE TO SUBMIT TO A STATE AND FEDERAL FINGERPRINTING AND BACKGROUND CHECK.

EMPLOYMENT OFFERS ARE CONTINGENT UPON THE RESULTS OF THE BACKGROUND SCREENINGS. PRE-EMPLOYMENT DRUG TESTING IS REQUIRED FOR ALL POSITIONS. EMPLOYMENT OFFERS ARE CONTINGENT UPON THE RESULTS.

MOST POSITIONS REQUIRE THE EMPLOYEE TO DRIVE. (IF YOU ARE REQUIRED TO DRIVE, YOU WILL ALSO BE REQUIRED TO SUBMIT A COPY OF YOUR CURRENT DRIVING RECORD AND SIGN A RELEASE OF INFORMATION REGARDING YOUR DRIVING RECORD.)
A. Do you have a current, valid driver’s license? A copy of a satisfactory driving record must be attached to qualify and maintain employment for most positions.*
- Yes
- No
B. Do you have use of a vehicle?*
- Yes
- No
C. Do you have proof of automobile liability insurance with the following minimum limits: $100,000/$300,000 per accident per person; $50,000 property damage; $10,000 medical payments which are required by acmhs to secure and/or maintain employment*
- Yes
- No
List your high school, college, university, graduate school information. Please include the name and location of the school, your course of study and degree completed.
Council for Higher Education Accreditation (Degrees must be endorsed by the council for higher education accreditation or other recognized accreditation bodies. Proof of graduate degree must be submitted with the application (official or unofficial transcript).
Do you have a national provider number (NPI)?*
- Yes
- No
If You’re Applying For A Clinical Position, This Number Will Be Required Before Employment Begins. Contact - https://nppes.cms.hhs.gov

If You Are A Licensed Professional, Please Provide License Number And Type.
List any achievements or activities that you consider relevant to your ability to perform the job for which you are applying, such as: awards received, memberships or offices held in professional organizations, licenses held, computer languages or software programs, foreign languages (proficiency in speaking, reading, and writing), etc.
Start with most recent employment. This information must be completed even if a resume is attached. If you show no work history for the past five years, explain where you were and what you were doing for those five years.
Employer's Name:
Employer's Address:
From:
To:
Job Title:
Ending Salary:
Immediate Supervisor:
Phone:
Description of Duties:
Reason For Leaving:
Employer's Name:
Employer's Address:
From:
To:
Job Title:
Ending Salary:
Immediate Supervisor:
Phone:
Description of Duties:
Reason For Leaving:
Employer's Name:
Employer's Address:
From:
To:
Job Title:
Ending Salary:
Immediate Supervisor:
Phone:
Description of Duties:
Reason For Leaving:
References (INCLUDE at least two supervisory references as well as their name, phone number and relationship to you.)
Personal Statement
I understand and agree that any omission, misrepresentation, or misstatement of material fact in this application and/or attached resume (if any) may result in refusal of or termination from employment. I agree to conform to the rules and regulations of ACMHS. If hired, my employment may be terminated at any time with or without cause or notice, at the option of either my employer or myself. I understand that no ACMHS representative has authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing. I also understand and agree to voluntary drug and alcohol testing for reasonable cause. I understand that refusal to comply may result in termination of employment.

I authorize ACMHS to verify all information provided by me on this application or in support of my efforts to obtain employment within ACMHS and to obtain any information relating to my employment with you. I further authorize you to release such information to ACMHS. I agree to hold harmless, and to absolve ACMHS and you from any and all liability, and hereby waive any claim I may have against ACMHS and/or you for any loss, damage, or injury that I may sustain as a result of ACMHS’ efforts to verify such information provided by me or any disclosure made in accordance with this authorization. I understand that if I have requested that my current employer not be contacted prior to accepting an offer of employment, that should I accept an offer, ACMHS intends to contact my former employer.
Please select 'Yes' to certify you agree with the personal statement.*
- Yes
Attach Resume:
Please type your name:*
This will act as your signature.
Please put in today's date:*

Our Vision

Wellness for Everyone!

Our Mission