Wasatch Mental Health Online Job Application
750 North Freedom Blvd, Suite 300 - Provo, Utah 84601
Phone (801) 852-4714 Email: Jobs@wasatch.org


Attention: If you do not receive a confirmation email your application was not submitted. Please check to make sure your email address is correct in the application.

Please select all positions you would like to apply for:
















Please Provide the following information:


Check if you will accept:
How did you find out about this job opportunity?
If other please explain:


I. APPLICANT INFORMATION

Last Name      First Name      Middle Initial
Other Name(s) Used
Address
City State Zip
Phone Number Email Address
Have you previously retired from WMH or any other entity under the URS system?
If so, please list your retirement date:



II. TRAINING AND EDUCATION: When claiming college, business, armed forces, or vocational school credit, you must submit transcripts or other official documents (original or photocopy) with your application. This information will be used to determine if you meet minimum qualifications.
 
Have you graduated from high school or received a high school equivalency diploma/GED?
If no, select the highest grade completed:
 
Name & Location of College
or University
Dates Credits Completed Major Minor Did You Graduate? Type of Degree Month & Year of Degree
From To Semester Hours Quarter Hours

PROFESSIONAL LICENSE OR CERTIFICATE, IF REQUIRED

Type Number Date Issued Expiration


III. LANGUAGES:  List languages you speak read and write other than English



IV. Experience: You must complete all items in these sections or your application may be rejected. Resumes or attachments may be considered only if these sections are completed. Statements such as "see resume or attachments" are not acceptable for these sections. The information you give regarding your experience will be used to determine if you meet minimum qualifications for the position. Begin with your present or most recent job and describe, in the boxes below, ALL periods of employment, such as paid (full or part time), volunteer (full or part time), self employment, and/or military service. Also, account for ALL periods of unemployment other than when attending school.

Employer's Name And Phone Number:
Complete Address:
Your Title: From MO./YR. To MO./YR.
Hours Per Week: Last Pay $ Per
Supervisor's Name, Title, and Phone Number:
Duties:
Reason For Leaving Or Seeking Other Employment:

Employer's Name And Phone Number:
Complete Address:
Your Title: From MO./YR. To MO./YR.
Hours Per Week: Last Pay $ Per
Supervisor's Name, Title, and Phone Number:
Duties:
Reason For Leaving Or Seeking Other Employment:

Employer's Name And Phone Number:
Complete Address:
Your Title: From MO./YR. To MO./YR.
Hours Per Week: Last Pay $ Per
Supervisor's Name, Title, and Phone Number:
Duties:
Reason For Leaving Or Seeking Other Employment:

Employer's Name And Phone Number:
Complete Address:
Your Title: From MO./YR. To MO./YR.
Hours Per Week: Last Pay $ Per
Supervisor's Name, Title, and Phone Number:
Duties:
Reason For Leaving Or Seeking Other Employment:

Employer's Name And Phone Number:
Complete Address:
Your Title: From MO./YR. To MO./YR.
Hours Per Week: Last Pay $ Per
Supervisor's Name, Title, and Phone Number:
Duties:
Reason For Leaving Or Seeking Other Employment:


V. References: List three persons who are not related to you and who have definite knowledge of your qualifications for the position for which you are applying.
Full Name Relationship Email Address Phone Number


1. Are you at least 18 years of age?

2. Since the age of 18, have you been convicted of a crime, excluding minor traffic offenses? If yes, give dates, details and penalties for each occurrence, including dates of any probationary periods. (Note: Each conviction will be judged in relation to time, seriousness, circumstances, and relationship to the position sought, and will not necessarily bar you from employment.) Explain:
3. Have you ever been discharged or forced to resign? Explain:

4. If the position for which you are applying requires driving a facility vehicle (see posted job announcement), do you possess a current valid driver’s license? Are you at least 21?  

5. Do you require a reasonable accommodation to apply for or to perform this job? If yes, please contact the Wasatch Mental Health human resources department at 801-852-4714.

6. Have you ever been an employee, intern or volunteer at WMH? If yes, please include applicable information in the experience section of this application.
7. Are you legally authorized to work in the U.S.?
8. Will you now or in the future require sponsorship from Wasatch Mental Health to continue working in the U.S.?

9. Are you related to someone currently employed by WMH? 

If yes, Name:  Relationship

10. Are you willing to have your current employer contacted regarding your employment record?

11. Have you ever had a license, certificate, permit, or registration to practice a regulated profession denied, conditioned, limited, restricted, suspended, revoked, reprimanded or disciplined in any way?

12. Are you currently under investigation or is any disciplinary action pending against you now by any local, state or federal licensing, enforcement or regulatory agency?



READ THE FOLLOWING PARAGRAPH CAREFULLY BEFORE SIGNING THIS STATEMENT:

I affirm that this application contains no misrepresentation or falsification and that the information is true and complete to the best of my knowledge and belief. I am aware that should investigation at any time disclose any such misrepresentation or falsification, my application will be rejected or, if employed by Wasatch Mental Health, I may be terminated from employment. I further authorize any of my previous employers (subject to my answer to the previous question regarding current employer) or references to give Wasatch Mental Health any private or confidential information concerning my employment record. I agree to hold harmless Wasatch Mental Health, its employees or any entity or person providing information about me. Finally, I authorize that copies of this form may be furnished to any hiring department.


Signature of Applicant (Sign by typing your name in the box) Date  (mm/dd/yyyy) (Required)



Invitation to Self-Identify Gender, Ethnicity/Race

WMH is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite applicants and employees to voluntarily self-identify their gender, race and ethnicity.

Submission of this information is strictly voluntary and refusal to provide it will not subject you to any adverse treatment.

The information obtained will be kept confidential and may only be used in accordance with the provision of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual. This information will be maintained separately from your application for employment. If you do not wish to self-identify at this time, you may do so in the future by submitting this form. Failure to provide the following information will not subject you to any adverse action or treatment.

WMH is an Equal OpporWMH is an Equal Opportunity/ Affirmative Action employer. We provide equal employment opportunities to all qualified employees and applicants for employment without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, veteran status, disability or any other legally protected status. We prohibit discrimination in decisions concerning recruitment, hiring, compensation, benefits, training, termination, promotions, or any other condition of employment or career development.

Gender:




Ethnicity/Race: