Job Opportunities with Michael Dunn



If you have not read our general employment information, please click HERE to learn about employment at the Michael Dunn Center before continuing with this application form.

If you would like to retrieve a previously saved job application form, please click HERE.

Michael Dunn Center - Employment Application Form

Please complete the following job application form, providing as much of the requested information as possible. Completion of fields marked with a "*" is required before the form can be submitted. Completion of fields marked with a "" is required before the form can be saved on-line. At the end of the application form, you will have the opportunity to include an electronic version of your resume (if you have one and wish to submit it). Note that we only accept resumes in Microsoft Word (file name ending with ".doc") or Adobe PDF (file name ending with ".pdf") formats. If you elect to include a resume with your application form, you must still complete all relevant parts of the application, even if the requested information is on your resume. When you have completed the form, simply click on the "Submit and/or Save" button at the bottom of the form.

 

Please enter all dates in this form in the format:
mm/dd/yyyy
- e.g., March 5, 2006 would be entered as 03/05/2006.

 

Please enter all phone numbers in the provided boxes in the format:
area code - phone number
- e.g., (865) 555-1212 would be entered as 865 - 555-1212.


Once we receive it, your application will remain on file for 6 months. After that period, if you have not heard from us and still wish to be considered for employment, it will be necessary to fill out a new application.

 

If you wish to save an application form that you have partially completed, first click the "Save & Do Not Submit" option at the end of the form and then click the "Submit and/or Save Application" button. To retrieve a previsouly saved form, click HERE and enter your form retrieval number at the prompt. Note that when you retrieve a saved form, the saved version will then be deleted.

 

Date: *
PERSONAL
SSN: *
Name: Last: *

First: *

Middle Initial: *

Maiden/Other:
(include all other names by which you have been known)
Preferred Name:  (the name you prefer to be called)
Address: Street: *

City: *

  State: *   Zip: *
Phone Number: Day: * - *

Evening: -

Work: -
Work Desired: Position or Type:
 

Date Available:
Preferred Status: Full Time   Part Time   Either


If part time, what hours?
Desired Shift:  Days   Evenings   Nights   Weekends   Any Shift
Preferred Days:  M   Tu   W   Th   F   Sa   Su

Uncheck each day (above) that you are UNWILLING to work
(days with a checkmark indicate days you are willing to work)
Eligibility:  Are you legally eligible for employment in this country?

Yes   No
Age:  Are you over 18 years of age?   Yes   No
History with MDC:  Have you ever applied here before?   Yes   No

If Yes, give date  

  Have you ever been employed here before?   Yes   No

If Yes, give dates From:   To: 
Employment Status:
Are you currently employed?   Yes   No
May we call you at work?   Yes   No
May we contact your current employer?   Yes   No
Are you on layoff and subject to recall?   Yes   No
Overtime Work: Will you work overtime, if asked?   Yes   No
Convictions: Have you ever been convicted of a felony?   Yes   No
Driving Data: Have you held a valid driver's license for 3 years?   Yes   No
  Has your driver's license ever been revoked?   Yes   No
  Will a review of your driving record reveal any citations?   Yes   No


If "Yes", please explain:


  Driver's License Number: *
(enter "No License" if you do not have a driver's license)

State of Issue: *
(select "Not Applicable" if you do not have a driver's license)
Tell Us Now: Is there anything which would affect your ability to perform the job for which you are applying?

Yes   No


If "Yes", please explain:

Certification: I, *, the undersigned applicant, certify and affirm that, to the best of my knowledge and belief; (I “have” or “have not”, as applicable) had a case of abuse, neglect, mistreatment or exploitation substantiated against me. As a condition of submitting this application and in order to verify this affirmation, I further release and authorize Michael Dunn Center, the Tennessee Department of Intellectual and Developmental Disabilities and the Bureau of TennCare to have full and complete access to any and all current or prior personnel or investigative records, from any party, person, business, entity or agency, whether governmental or non-governmental, as pertains to any allegations against me of abuse, neglect, mistreatment or exploitation and to consider this information as may be deemed appropriate. This authorization extends to providing any applicable information in personnel or investigative reports concerning my employment with this employer to my future employers who may be Providers of DIDD services.
EDUCATION, SKILLS, & PROFESSIONAL MEMBERSHIPS
High School: Years Completed 0   10   11   12

(click the highest grade level)


 
  Did you receive – a Diploma  a GED  Neither

Under what name did you attend/graduate?

School Name –

  School Address – City:  State:
College: College type 2 Year   4 Year
Years Completed 1   2   3   4   4+

(click on the highest year)
Degrees Received (check all that apply):

 AA/AS    BA/BS    MA/MS    Ph.D/MD    Other
School Name –
School Address – City:

School Address – State:
Other: Certificates   Licenses   Nursing License (check all that apply)

If Nursing License, License Number is:
Skills, Etc.: List other skills or qualifications that would be of benefit in the performance of your job:

Memberships: List any professional, trade business or civic organizations to which you belong or are associated:
1.  2.

3.  4.

5.  6.
REFERENCES
Job Referral: How did you find out about this job?



If referred, List Referral’s name –
References: List name and telephone number of at least three business or work references who are not related to you. If not applicable, list at least three school or personal references.
Name Phone Number Years Known
EMPLOYMENT HISTORY
Must include at least 5 years history of employment or other activity.
If you've only had one job during the past 5 years, please list additional jobs you may have had. Please explain any gaps in employment history (see "Additional Information" later in this section)
Employer 1: Name

Telephone Number -

Street Address

City

State:   Zip:


Dates Employed: From  To

Job Title:

Salary: Starting  Final

Employed under what name?

Work performed:

Immediate Supervisor:

Supervisor Title:
 
Reason for leaving:
Employer 2: Name

Telephone Number -

Address

City

State:   Zip:


Dates Employed: From  To

Job Title:

Salary: Starting  Final

Employed under what name?

Work performed:

Immediate Supervisor:

Supervisor Title:
 
Reason for leaving:
Employer3: Name

Telephone Number -

Address

City

State:    Zip:


Dates Employed: From  To

Job Title:

Salary: Starting  Final

Employed under what name?

Work performed:

Immediate Supervisor:

Supervisor Title:
 
Reason for leaving:
Employer 4: Name

Telephone Number -

Address

City

State:        Zip:


Dates Employed: From  To

Job Title:

Salary: Starting  Final

Employed under what name?

Work performed:

Immediate Supervisor:

Supervisor Title:
 
Reason for leaving:
Additional 
Information:
Please provide any additional information that you consider important:
UNDERSTANDINGS & PERMISSIONS
Please Read Carefully: It is understood that any misrepresentation by me on this application will be sufficient cause for cancellation of this application and/or separation from the employer’s service if I have been employed.

 

I give the employer the right to investigate all references and to secure additional information about me, if job related.

 

I give permission for you to contact my former employers concerning my past job performance. I further release my former employers from any liability to me concerning their descriptions of my performance. I hereby release from liability the employer and it’s representatives for seeking such information and all other persons, corporations or organizations for furnishing such information.

 

 
 

I authorize Security Walls, LLC to make whatever inquiries it deems necessary in connection with my application for employment or in the course of review of any employment. I authorize all persons, schools, companies, corporations, credit bureaus, department of motor vehicles and law enforcement agencies to supply information concerning my background. I release Security Walls, LLC, Equifax, and all persons who provide information to Security Walls, LLC concerning me, harmless from all liability or any damages resulting from the inquiry and the furnishing of said information.

A photocopy of this authorization shall be deemed an original and shall be accepted as such by every person. I understand that I have the right to request a copy of any report by writing to Security Walls, LLC within 60 days. The fee for this report will be paid at my expense to Security Walls, LLC. As per the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained from a consumer reporting agency such as Security Walls, LLC.


The employer is an Equal Opportunity Employer. The employer does not discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant’s consideration for employment on a basis prohibited by local, state or federal law.

 

I understand it is the company’s policy not to refuse to hire a qualified individual with a disability because of this person’s need for an accommodation that would be required by the ADA.

 

I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice.

 

I understand that no representative of the employer has the authority to make any assurances to the contrary.

 

I understand that a criminal background check will be done before I am considered for employment. I give permission for my background to be checked.

 

This application will be kept on file for 6 months. At the conclusion of this time, if I have not heard from the employer and still wish to be considered for employment, it will be necessary to fill out a new application.

 
Release 
Authorization:
First Name *  Middle Initial *

Last Name *

Social Security Numner (SSN): *

Date *     Date of Birth *
 
Form Save Options
 


When you click the "Submit and/or Save Application" button, one of the following will occur.
Submit &
Do Not Save


Submit & Save
Save &
Do Not Submit

NOTE: A saved form will be automatically deleted either 31 days after it has been saved or immediately after it has been retrieved.

Include Resume
(only PDF or MS Word files accepted)

   

<--- (see Save Options on the left)    
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