Application for: Clinical Volunteer Position

Mid-Ohio Psychological Services, Inc (MOPS) is an equal opportunity employer and considers applicants for all positions without regard to race, color, religion, sex, national origin, age, marital or veteran status, the presence of a non-job-related medical condition or handicap, or any other legally protected status.

Basic Information

* First Name
Middle Name .
* Last Name
City: State: Zip:
Social Security Number: * Contact Phone: * Contact Email:

Applicant Information

Salary Desired:
First Date Available:
Hours Available:
How were you referred to MOPS?:
Are you currently employed?:
Are you on a lay-off and subject to recall?:
Can you travel if the job requires it?:
Have you ever been convicted of/pled guilty or no contest to a crime including traffic violations? This agency conducts background checks under the reason code of Medicaid Provider. As a Medicaid Provider, the agency is required to exclude applicants with convictions listed on the Ohio Disqualifying Offenses List and in some cases, even sealed records will appear on a background check when it is conducted. If you have any questions, please reach out to HR at

Are you a U.S. citizen?:
Have you lived outside Ohio in past 5 years?:
Any known scheduling restrictions or conflicts?: Characters Remaining: 400/400

Military Background Information

Are you currently or formerly part of the Military?