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As a leader in the delivery of addiction treatment, Mirror Inc. provides a variety of treatment programs, from assessments to residential treatments, in many different communities.
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.
Offender = client or ex-client by definition as noted in Mirror personnel policies.
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
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
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
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.