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Name

First Name*

Last Name*

MI

Contact Information

Address*

Street Address City State / Province / Region ZIP / Postal Code

Home Phone*

Business Phone

Cell Phone

Email

Application History

Have you ever applied for employment with us Before

If yes Applied Month

Applied Year

Please enter a number from 1920 to 2040.

Applied Location

Mirror Inc. Employment History

Have you ever been employed with us before*

If yes give dates

Job Info

Are you over 18 and legally eligible for employment in the United States:

Apart from absence for religious observance, are you available for full-time work:

Overtime, if asked:

Can you travel if required by job:

Pay expected:*

Pay per:

Have you read the job description related to this job and do you understand and are you able to perform all of these essential job functions:

When can you begin work:*

Mirror is a multi-site agency. Which location or locations are you most interested in working at? Please state the city or cities in which you will consider working:*

Are you willing to relocate:

Organization Membership

Membership in Professional or Civic Organizations: (For your protections under the law, you may wish to exclude those that may disclose your race, color, religion or national origin)

Military Experience

Did you serve in the U.S. Armed Forces:

If “Yes,” in which Branch:

Describe any training received relevant to the position for which you are applying:

Additional Information

Have you ever been bonded:

If yes, with what employers:

State the names of relatives and friends working for us, other than your spouse:

Indicate any foreign languages you can speak read and/or write and rate your level of skill using the categories: Fluent, Good or Fair.

Please describe in detail the levels of proficiency on the various computer programs you are skilled in:

Summarize special job-related skills and qualifications acquired from employment or other experience

Please list any licenses or credentials you have that might be relevant to this position (LAC, LCAC, LPN, RN, etc…):

Indicate any additional information you feel may be helpful to us in considering your application:

Education History

School #1

School Type*

School Name*

School Location*

Course of Study*

No. of Years Completed*

Degree or Diploma Obtained*

Did You Graduate?*

Would you like to add a second school/institution?

School #2

School Type*

School Name*

School Location*

Course of Study*

No. of Years Completed*

Degree or Diploma Obtained*

Did You Graduate?*

Would you like to add a third school/institution?

School #3

School Type*

School Name*

School Location*

Course of Study*

No. of Years Completed*

Degree or Diploma Obtained*

Did You Graduate?*

Would you like to add a forth school/institution?

School #4

School Type*

School Name*

School Location*

Course of Study*

No. of Years Completed*

Degree or Diploma Obtained*

Did You Graduate?*

Would you like to add a fifth school/institution?

School #5

Please upload your resume later in the application process.

Employment History

Are you currently employed:*

May we contact your present employer:*

Do you have relevant employee history for the position for which you are applying?*

Previous Employers

Please enter your most recent employer first.

Employer #1

Company Name*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone*

Employed From Year*

Employed To Year*

Supervisor*

Hourly wage or annual pay when you left this employer*

Pay Per*

Job Title*

Reason for leaving*

Describe your work*

Would you like to enter a second employer?*

Employer #2

Company Name*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone*

Employed From Year*

Employed To Year*

Supervisor*

Hourly wage or annual pay when you left this employer*

Pay Per*

Job Title*

Reason for leaving*

Describe your work*

Would you like to enter a third employer?*

Employer #3

Company Name*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone*

Employed From Year*

Employed To Year*

Supervisor*

Hourly wage or annual pay when you left this employer*

Pay Per*

Job Title*

Reason for leaving*

Describe your work*

Would you like to enter a forth employer?*

Employer #4

Company Name*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Phone*

Employed From Year*

Employed To Year*

Supervisor*

Hourly wage or annual pay when you left this employer*

Pay Per*

Job Title*

Reason for leaving*

Describe your work*

Would you like to enter a fifth employer?*

Employer #5

Please upload your resume later in the application process.

References

Please enter your references. We require at least three professional references.

Reference #1

Type*

Name*

Primary Phone*

Other Phone

Email Address*

In what capacity has this person known you?*

Reference #2

Type*

Name*

Primary Phone*

Other Phone

Email Address*

In what capacity has this person known you?*

Reference #3

Type*

Name*

Primary Phone*

Other Phone

Email Address*

In what capacity has this person known you?*

Would you like to include a forth reference?

Reference #4

Type

Name

Primary Phone

Other Phone

Email Address

In what capacity has this person known you?

Would you like to include a fifth reference?

Reference #5

Type

Name

Primary Phone

Other Phone

Email Address

In what capacity has this person known you?

Background

Are you currently on probation or parole:

Have you ever been convicted of a felony(ies):

If yes, please describe:

Within the past three years, have you had a misdemeanor conviction involving assaultive, abusive and/or violent behavior such as: sexual assault, sexual abuse of another, sexual abuse of a minor, domestic violence, etc.?

If yes, please describe:

Have you had two or more misdemeanor convictions within the last three years:

If yes, please describe:

Have you had three or more seperate instances of moving traffic violations within the last year:

If yes, please describe:

Have you had two or more driver’s license suspensions/revocations within the last three years:

If yes, please describe:

Within the past three years, have you had two or more convictions for driving while intoxicated or driving under the influence:

If yes, please describe:

Within the past three years, have you had two or more convictions for drunk and disorderly conduct or public intoxication:

If yes, please describe:

Have you had one or more instances of physical force resulting in physical harm or medical attention required to another, except in self-defense or to prevent physical harm to another, within the past five years?

If yes, please describe:

Code of Conduct

Mirror employees are expected to meet a code of behavior or conduct that requires “due diligence” to the workplace and on-going professionalism. Please review the “Employee Standards of Conduct” below.

Employees will conduct themselves professionally and in a manner that creates and maintains respect for the RRC, Mirror, KDOC, BOP, DOJ & the United States Government.
Employees will avoid any action that might result in, or create the appearance of, adversely affecting the confidence of the public in the integrity of the RRC, Mirror, KDOC, BOP, DOJ & the United States Government.
Employees shall uphold all ethical rules and standards of their professions, including applicable licensing authority rule, unless they conflict with legal laws.
Employees shall not use or possess illegal drugs or narcotics
Employees shall not abuse any drugs or narcotics.
Employees shall not use or be under the influence of alcohol while on duty or present in the facility, or within 8 hours of reporting for duty. (An employee who has a blood alcohol level of .02 will be considered to be under the influence.)
Employees shall not show partiality toward, or become emotionally, physically, sexually, or financially involved with program participants or former program participants.
Employees shall not engage in, nor allow another person to engage in, sexual behavior with a program participant. (There can be no “consensual sex” between employees and program participants).
Employees shall not offer or give a program participant, a former program participant or any member of a program participant’s family, or to any person known to be associated with a program participant, any article, favor, or service which is not authorized in the performance of the employee’s duties.
Employees shall not accept any gift, personal service, or favor from a program participant or a former program participant or from anyone known to be associated with or related to a program participant or a former program participant. This prohibition includes becoming involved with program participant’s families or associates of any program participant.
Employees shall not show favoritism or give preferential treatment to one program participant, or a group of program participants, over another program participant.
Employees shall not use profane, obscene, or otherwise abusive language when communicating with program participants, fellow employees, or others.
Employees shall conduct themselves in a manner that is not demeaning to program participants, fellow employees, or others.
Employees shall remain fully alert & attentive during duty hours.
Employees shall not have any outside contact with a program participant, former program participant, program participant’s family or close associates, for a period of one (1) year from the last day of the program participant’s discharge (or if under the supervision of the criminal justice system) sentence or supervision, whichever is later, except those activities that are an approved, integral part of the Mirror or the RRC program and a part of the employee’s job description. Note: For licensed counselors this would extend to 2 years.
Employees shall not engage in any conduct that is criminal in nature or which would bring discredit upon the RRC, Mirror, KDOC, BOP, DOJ & the United States Government.
Employees shall conduct themselves in a manner that is above reproach.
Employees shall obey, not only the letter of the law, but also the spirit of the law while engaged in personal of official activities.
Employees who are charged with, arrested for, or convicted of any felony or misdemeanor will immediately inform and provide a written report to the Mirror President/CEO. If the employee works in the RRC the report should be routed to the Mirror Director of Federal Programs (Facility Director). The Facility Director will immediately report the incident to the COTR. (Traffic violations resulting in fines less than $150.00 are exempt from this reporting requirement.)
Employees shall not use brutality, physical violence, or intimidation toward program participants, or use any unauthorized or excessive force.
Employees shall not engage in inappropriate supervisor/subordinate relationships, to include, but not limited to, emotional, sexual, financial or physical.
Employees shall not possess lethal weapons or weapons which may inflict personal injury, to include pepper spray or other self-defense type of chemical agents, in the facility or while on duty.
Employees shall not store lethal weapons or weapons which may inflict personal injury, to include pepper spray or other self-defense type chemical agents, in vehicles under their control parked on or adjacent to the facility. (Program participants are not allowed to possess these items at any time.)
Employees who are suspected of violating the Employee Standards of Conduct shall not have contact with Federal Offenders until a disposition is made by the COTR. This would also apply to employees of other Mirror programs and the disposition of the said employee will be at the discretion of the Mirror President/CEO.
An investigation of any misconduct allegation for RRC contracted employees shall not be conducted without the approval of the COTR. (This includes questioning.) All employees are subject to Government investigation if an allegation is made concerning any matter affecting the interests of the Government.
For Mirror RRC employees any allegation, violation or attempted violation of the Employee Standards of Conduct shall be reported immediately, by phone to the COTR. A written report of the incident will be submitted to the COTR within 24 hours. All employees, as well as offenders, have the right to report misconduct directly to the BOP without fear of retaliation. A similar procedure shall be followed for other Mirror programs. The written report shall be submitted to the Mirror President/CEO.
An employee will not, under any circumstances, use his or her official position working with program participants or federal offenders to secure privileges or advantages in the facility or in the community.
Employees will perform their duties in a manner that ensures the highest degree of safety for program participants and employees.
Employees are prohibited from using excessive force to control a situation.
Use of force will be immediately reported to the COTR in the most expeditious manner (telephone, e-mail) and a written report will be submitted to the COTR within 24 hours. A similar procedure will be followed for other Mirror programs with the written report routed to the President/CEO.
Employees are prohibited from engaging in any type of sexual abuse/assault/misconduct against program participants, former program participants or other employees. This includes harassment and intimidation.

Offender = client or ex-client by definition as noted in Mirror personnel policies.

Are you able to live up to these standards:

If no, please describe:

Employment Application

MUST BE COMPLETED IN FULL AND SIGNED BY THE APPLICANT.

FALSIFICATION OF APPLICATION INFORMATION:

I understand that falsification of information, misleading information, any misstatement, or omission of fact on this application or during the interview process may be cause for immediate withdrawal of employment eligibility or, in the event of employment, may be cause for immediate dismissal. I certify that answers given herein are true and complete.

RELEASE OF INFORMATION:

I understand and agree that previous employers, personal references, and educational institutions may be asked for information concerning my employment, character, ability, and/or job experience. I understand that this information will be used by Mirror supervisory staff for the hiring decision and I release any person giving or receiving such information. Furthermore, I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

STATEMENT OF CONFIDENTIALITY:

I understand that, should I be employed by Mirror, Inc., all personal information involving clients or staff of Mirror, Inc., which I obtain or become aware of as a result of my employment, is to be kept confidential and that unauthorized divulgence of such information may lead to dismissal. Please see Federal Register (Volume 52. Number 110 Part II) 42 CFR (Part 2) & 45 CFR (commonly known as HIPAA) for details. I understand, also, that I am required to abide by all rules and regulations of the employer.

CREDENTIALS/REFERENCE CHECKS:

I understand that employment with Mirror, is contingent upon receiving a positive report from the Kansas Department of Corrections, Bureau of Prisons, Federal Bureau of Investigation or IntelliCorp, Inc., according to Mirror personnel policies. Mirror will run a thorough and extensive background checks on all employees and volunteers. After the employee is initially hired a “Request for Background Check Form” and/or fingerprint cards will be obtained on all employees. Employees are “conditionally hired” until all background check information is returned. Information from those checks will be used to determine whether or not the employee can have access to offenders/clients. Once the background checks are complete the employee will be informed of the results. If they are denied access or authorization, they will be terminated since they are unable to perform an essential job function. If they believe the denial to be unwarranted, they may file a formal (in writing) challenge.

STATEMENT OF INSURABILITY:

Since operating a vehicle may be a necessary part of the job for which you are applying, your potential employment and, if hired, your continued employment, are contingent upon your being insurable by Mirror’s insurance carrier as a vehicle operator. Persons who drive Mirror vehicles must be at least 18 years of age with a good driving record and insurable on Mirror’s insurance. Persons who do not meet these criteria will not be authorized to drive Mirror vehicles. For insurance reasons, we routinely confirm all driving records of newly hired staff that will be operating agency vehicles. The purpose, of course, is to protect the persons we serve from endangerment and to prevent Mirror from possible legal action.

EMPLOYER AT WILL:

I understand that any employment that might be offered to me by Mirror is ‘at-will’ and of indefinite duration, that either I or Mirror may terminate that employment at any time, with or without notice and for any reason, that no agreement to the contrary will be recognized by Mirror unless such agreement is in writing and signed by the President/CEO and the Mirror Board of Directors. I understand if I am offered employment and accept, this employment application form becomes part of the terms and conditions on my employment.

LENGTH OF APPLICATION:

I understand this application for employment shall be considered active for a period of time not to exceed 60 days. Any applicant willing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

CERTIFICATION AND RELEASE:

I certify that I have read and understand the applicant note on page one of this form and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, omissions or misrepresentations of facts called for in this application, whether on this document or not, may result in rejection of my application or discharge at any time during employment. I authorize Mirror and/or its agents, including consumer-reporting bureaus, to verify this information. I authorize all former employers, persons, schools, companies, and law enforcement authorities from any liability for any damage whatsoever for issuing this information. I understand that the use of illegal drugs is prohibited during employment. If company policy requires, I am willing to submit to drug testing to detect the use of illegal drugs prior to and during employment.

REFERENCE/CREDENTIALS VERIFICATION AUTHORIZATION BY FAX OR MAIL

I authorize my current and previous employers to give Mirror information concerning my employment, character, ability and/or job experience: I understand that this information will be used by Mirror supervisory staff for the hiring decision and I release any person giving or receiving such information.

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Date

Programs

Services

Apply for this Position

Name

Contact Information

Application History

Mirror Inc. Employment History

Job Info

Organization Membership

Military Experience

Additional Information

Education History

School #1

School #2

School #3

School #4

School #5

Employment History

Previous Employers

Employer #1

Employer #2

Employer #3

Employer #4

Employer #5

References

Reference #1

Reference #2

Reference #3

Reference #4

Reference #5

Background

Code of Conduct

Employment Application

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