Employment Pre-Application

Use this form to tell us a little more about yourself and your abilities. Please understand that this is NOT an official application for employment. If you are considered for employment with TML IEBP, you will be required to complete an official employment application.

Personal Information

Position applied for: --- [please choose a position] --- Behavioral Health Coach - PTMember Service Rep/PhonesNone Specified * Desired Pay Range: * Last Name: * First Name: *  Middle Initial: Social Security Number: * Address: City: State: -- AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY   Zip Code: Home Telephone #: Work/Other Telephone #: Email address: How did you hear about this position?: Please Select Advertisement Referral Website Other   If Other, Pleaes Specify:

Employment History

Current Employer: Telephone #: Dates Employed: From    To Address: (City & State) Starting/Final Job Title: Immediate Supervisor/Title: May We Contact? Yes   No   Later Summarize the Nature of Work Performed and Job Responsibilities: Reason for Leaving: Previous Employer #1: Telephone #: Dates Employed: From    To Address: (City & State) Starting/Final Job Title: Immediate Supervisor/Title: May We Contact? Yes   No   Later Summarize the Nature of Work Performed and Job Responsibilities: Reason for Leaving: Previous Employer #2: Telephone #: Dates Employed: From    To Address: (City & State) Starting/Final Job Title: Immediate Supervisor/Title: May We Contact? Yes   No   Later Summarize the Nature of Work Performed and Job Responsibilities: Reason for Leaving:

Educational Background

High School Name & Location: Number of Years Completed: Did you Graduate? Yes   No Major Course of Study College Name & Location: Number of Years Completed: Did you Graduate? Yes   No Major Course of Study Other Name & Location: Number of Years Completed: Did you Graduate? Yes   No Major Course of Study

Skills/Abilities

Do you Type? YES     NO       If Yes, How many Words Per Minute? wpm Please describe any skills you have in the following areas: Programming language(s): Computer software/hardware: Other skills/abilities: Licenses/Certificates:

Professional References

Name: Telephone #: Occupation: Years Known: Name: Telephone #: Occupation: Years Known: Name: Telephone #: Occupation: Years Known:

Resume & Cover Letter

If you would like to submit a Resume or Cover Letter, please attach either Word (.doc) or Text (.txt) documents using the "Browse" buttons below. Resume: Cover Letter:

Certification and Authorization

I certify that all information I have provided in order to apply for and secure work with the TML Intergovernmental Employee Benefits Pool (TML-IEBP) is true, complete and correct and that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (i) cancel further consideration of this application, or (ii) immediately discharge me from TML-IEBP, whenever it is discovered. I expressly authorize, without reservation, TML-IEBP and its representatives to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resumé or job interview. I hereby release from liability TML-IEBP and its representatives for seeking, gathering and using such information in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that TML-IEBP does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law. I understand that this application remains current for only 90 days. At the conclusion of that time, if I have not heard from TML-IEBP and still wish to be considered for employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and TML-IEBP reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of TML-IEBP is authorized to make any assurances to the contrary and that no implied, oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by TML-IEBP's Executive Director. I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United states and that federal immigration laws require me to complete an I-9 Form in this regard. By submitting this form, I certify that I have read, fully understand, and accept all terms of the foregoing and seek employment under these conditions.

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