Application Form     (* indicates required field)

First Name*

Last Name*

Email*

Phone*

Country:* United States Canada-------------Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia, Plurinational State of Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, The Democratic Republic of the Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Côte d'Ivoire Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States of Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palestine, State of Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Qatar Romania Russian Federation Rwanda Réunion Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands

Address 1:*

Address 2:

City:*

State:* Please choose Alabama Alaska American Samoa Arizona Arkansas Armed Forces Africa, Canada, Europe, Middle East Armed Forces Americas (except Canada) Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas United States Minor Outlying Islands Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming

Zip Code:*

Please attach the following files

Please answer the following questions to help us better evaluate your application.

1. POSITION TITLE *
2. Please acknowledge your understanding this position may be either in Marina, Monterey or Salinas. *
   -- Select One --Acknowledged
3. Are you currently an Interim, Inc. employee? *
   Yes No
4. If yes to above question, desired location? (internal applicants only) *
5. Where did you first view this job posting? *
   Other Monterey Bay Help Wanted Monterey Bay Jobs Linked In Indeed Glassdoor CSUMB (Otter Jobs) Craigslist Career Builder Interim Employee Interim Website
6. ARE YOU UNDER 18? *
   Yes No
7. BEST PHONE NUMBER TO USE FOR MESSAGES *
8. ARE YOU RELATED TO OR LIVING WITH AN INTERIM EMPLOYEE OR BOARD MEMBER? *
   Yes No
9. IF YES TO THE ABOVE, PLEASE ENTER EMPLOYEE OR BOARD MEMBER NAME:
10. PREVIOUSLY APPLIED TO INTERIM? *
    Yes No
11. IF YES TO THE ABOVE, PLEASE ENTER DATE & POSITION:
12. SALARY DESIRED: *
13. DO YOU HAVE A VALID DRIVER’S LICENSE? *
    Yes No
14. Please select State in which you have your Driver's License. If you do not have one, select "No Driver's License". *
    No Driver's License AL AK AZ AR CA CO CT 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
15. DO YOU HAVE ACTIVE LIABILITY INSURANCE? *
    Yes No
16. DO YOU OWN/HAVE ACCESS TO VEHICLE? *
    Yes No
17. AVAILABLE FOR WORK : *
    FULL-TIME PART-TIME TEMPORARY
18. AVAILABLE FOR HOURS: *
    DAY EVENING OVERNIGHT
19. DATE YOU CAN START: *
20. IF EMPLOYED, YOU WILL BE REQUIRED TO SUBMIT VERIFICATION OF YOUR LEGAL RIGHT TO WORK IN THE U.S. AS REFERENCED BY THE IMMIGRATION REFORM ACT OF 1986. IF EMPLOYED, CAN YOU SUBMIT VERIFICATION OF YOUR LEGAL RIGHT TO WORK IN THE UNITED STATES? *
    Yes No
21. INTERIM COMPLIES WITH THE AMERICANS WITH DISABILITIES ACT. ARE YOU ABLE TO PERFORM THE ESSENTIAL DUTIES OF THE POSITION FOR WHICH YOU ARE APPLYING, EITHER WITH OR WITHOUT REASONABLE ACCOMMODATIONS? *
22. IF APPLICABLE TO THE POSITION WHICH YOU ARE SEEKING, INDICATE OTHER SKILLS SUCH AS TYPING SPEED, SPECIFIC COMPUTER PROGRAM EXPERIENCE, AND LEVEL OF PROFICIENCY:
23. ARE YOU CURRENTLY A SMOKER (CIGARETTES OR OTHER TOBACCO PRODUCTS)? Interim is a smoke-free workplace and gives preference to the hiring of non-smokers who are qualified for open positions. Interim employees may be required to interact with residents and/or clients of their programs who are smokers. Although smoking is allowed only in designated areas, there may be the odor or scent of tobacco products present. *
    Yes No
24. DO YOU SPEAK, WRITE &/OR UNDERSTAND SPANISH? *
    Yes No
25. IF YES TO THE ABOVE, PLEASE NOTE LEVEL OF PROFICIENCY:

OFFENSES

26. (Please note: No applicant will be denied employment solely on the grounds of a criminal conviction. Offense, date, circumstances, relevance to position applied for and State licensing regulations may be considered. Failure to disclose misdemeanor or felony convictions will result in termination or denial of employment. Verification of criminal record and DMV record is required for employment at Interim.)
    A. Have you ever been convicted of any criminal offense? (You may omit offenses settled in juvenile court or under a welfare youth offender, misdemeanor convictions for marijuana-related offenses that are more than two years old, or convictions that have been judicially expunged, sealed or eradicated and misdemeanor convictions for which probation has been completed and the case judicially dismissed. *
    Yes No
27. B. Have you had any convictions for moving violations in the past 3 years? Have you had any convictions for driving under the influence (DUI), reckless driving or hit and run? You may omit violations that do not appear on your DMV record due to attendance at a driving class. *
    Yes No
28. If your answer to question A or B above is YES, please provide the following information: Date, Location, Offense, & Disposition

EDUCATION & TRAINING

29. SELECT HIGHEST GRADE COMPLETED *
    -- Select One --HIGH SCHOOL HIGH SCHOOL DIPLOMA GED COLLEGE (1) COLLEGE (2) COLLEGE (3) COLLEGE (4) POST-GRADUATE
30. INDICATE HIGH SCHOOL NAME, LOCATION & DEGREE/CERTIFICATE: *
31. INDICATE COLLEGE NAME, LOCATION, MAJOR SUBJECT, UNITS, & DEGREE/CERTIFICATE:

LICENSES, CERTIFICATIONS, OR PROFESSIONAL REGISTRATIONS (You may omit associations which indicate race, religious creed, color, national origin, ancestry, sex, or age.)

32. PLEASE INDICATE TYPE, NUMBER & EXPIRATION DATE OF ANY LICENSES, CERTIFICATIONS OR PROFESSIONAL REGISTRATIONS THAT YOU POSSESS:
33. PROFESSIONAL ORGANIZATIONS, SOCIETIES, MEMBERSHIPS:

EXPERIENCE

34. List ALL of your work experience for the last 20 years, beginning with your current or most recent experience.
    
    NOTE: In the next question, you will be asked to list hours worked per week in each position. Include all positions held, to include military service. Include volunteer services if related to this position. Experience beyond 20 years ago should be included if it is directly related to the position for which you are applying.
    
    Do not write “See Resume.” THIS SECTION MUST BE COMPLETED. Failure to follow these instructions may eliminate you from consideration for the position. *
35. PLEASE INDICATE THE NUMBER OF STANDARD HOURS PER WEEK YOU WORKED FOR EACH OF THE ABOVE POSITIONS: *
36. Have you ever been fired from a job or forced to resign? *
    Yes No
37. If you answered YES to the question above, please describe circumstances:

REFERENCES: List below three persons who have knowledge of your work performance. These individuals should not be related to you.

38. REFERENCE 1 OF 3: LIST NAME, ADDRESS, OCCUPATION, TELEPHONE NO., & NUMBER OF YEARS ACQUAINTED: *
39. REFERENCE 2 OF 3: LIST NAME, ADDRESS, OCCUPATION, TELEPHONE NO., & NUMBER OF YEARS ACQUAINTED: *
40. REFERENCE 3 OF 3: LIST NAME, ADDRESS, OCCUPATION, TELEPHONE NO., & NUMBER OF YEARS ACQUAINTED: *
41. Please read and agree to the Disclosure Statement below. If you request any Exceptions (per the second paragraph of the Disclosure), please list below the Exception and Reason for Exception:
42. I would like to waive receipt of a copy of any public record described in the Disclosure Statement below.

Interim, Inc. is an equal opportunity employer.

EMPLOYMENT APPLICATION SUPPLEMENT - COUNSELOR These supplemental questions are intended to provide detailed information about your experience related to this position.

43. Please describe your experience working with adults with psychiatric disabilities? *
44. Please describe your experience working with individuals with substance abuse problems? *
45. Please describe other counseling/crisis intervention experience? *
46. Please describe your experience working in residential treatment or in social rehabilitation programs? *
47. “Does your experience amount to at least one year full-time (2080 hours) working with adults with mental illnesses?” *
48. Please describe your experience facilitating groups; planning activities and/or recreational events? *
49. Please describe your experience working as a team member? *
50. Please describe your experience with documenting according to Medi-Cal requirements? *
51. Where did you hear about us? *
    Please choose Interim Website Career Builder Craigslist CSUMB (Otter Jobs) Dice Google Interim Employee Indeed Linked In Monster Monterey Bay Help Wanted Monterey Bay Jobs Nurse.com SEES Other Website

You will receive confirmation after we have received your application.