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The Specialized Treatment Facility is accepting Bids for Beautician and/or Barber Services for
our residents. Applicants to provide hair care services must complete an Application for
Employment, a Work References Packet, submit to fingerprint criminal background check, and
drug and alcohol screen. A current MS license and proof of professional liability insurance is
also required.
Upon clear background checks and work references, STF will contact the applicant to complete
a contract for services. The Vendor will be required to attend a brief orientation (30 minutes) in
order to become familiar with STF rules and regulations.
The facility has a fully equipped Salon/Barber shop in order to provide hair care for our
residents. Services will be provided on a monthly basis for approximately 38 residents between
the ages of 13 and 18. The attached bid sheet contains a list of services we are currently
providing and that we are seeking bids for. This contract will cover a one-year period beginning
July 1, 2020 through June 30, 2021 with two (2) one-year renewals available.
Hair care services are provided to the residents on a predetermined schedule that is mutually
agreed upon by the provider and STF. Scheduling may be negotiated; however, it would need
to be approved in advance.
Services are to be performed between 8 a.m. and 2:30 p.m.
Upon completion of each day’s services, the vendor will complete and submit a Hair Care
Service Invoice supplied by STF for services rendered. Invoices are normally paid electronically
within 10-14 working days. Payments will be made in accordance with State of Mississippi
payment guidelines.
If you are interested in providing these services please complete an Application for
Employment, a Work Reference Packet, and the following Bid Sheet and call for an
appointment to schedule an interview/visit of the facility. If you have any questions please call
Dawn Clayton at 228-328-6000 Ext. 111 or email [email protected].
Specialized Treatment Facility
14426 James Bond Road
Gulfport, MS 39503
228-328-6000, Ext. 103
228-328-6035 FAX
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HAIR CARE SERVICES BID SHEET
The following is a list of services we are currently providing and requesting bids.
All hair care products are to be furnished by the beautician.
Prices are for each individual service.
Services to be Performed
Boys
Girls
Shampoo/Blow Dry
_____________
____________
Shampoo/Cut
_____________
____________
Shampoo/Cut/Blow Dry
_____________
____________
Shampoo/Blow Dry/Flat Iron or Curl
_____________
____________
Flat Iron or Curl Only
_____________
____________
Hair Cut Only
_____________
____________
Clipper Cut with Line
Braiding
Hair Cut (with *Relaxer)
_____________
____________
*Relaxer Only
_____________
____________
*Relaxer may only be used to maintain hair that has been previously relaxed.
Treatments listed below if needed:
Hair Protein Treatment
_____________
____________
Conditioner Treatment
_____________
____________
Dandruff Treatment
_____________
____________
Printed Name: _________________________________________________________________
Signature: _________________________________________ Date: ____________________
DBA: _________________________________________________________________________
State License Number: ____________________ Telephone: ____________________________
Address: ______________________________________________________________________
--- A Program of the Mississippi Department of Mental Health ---
HRD-021 Revised: 07/18/2018
Applicant Background / Work Reference Packet
Please fill out this packet completely. This information is necessary to process background
checks and work references.
Work references must be for your
current and last two employers
; or if not currently employed,
your
last three employers
. The work references must match the work experience listed on your
application.
_____________________________
Printed
Applicant
Name
Previous
Name
Date
of
Birth
Social
Security
Number
Day-time Phone Number
SPECIALIZED TREATMENT FACILITY
14426 James Bond Road, Gulfport, MS 39503 Phone: (228) 328-6000 Fax: (228) 328-6035
Shannon Y. Bush, MPA, Program Director
--- A Program of the Mississippi Department of Mental Health ---
HRD—021 Revised 07/18/2018
APPLICANT BACKGROUND QUESTIONNAIRE
Under Federal guidelines, the Specialized Treatment Facility must conduct background checks on all potential
applicants. As part of these background checks, we will cooperate with local law enforcement agencies to
determine whether or not a criminal conviction is on file. This will aid the Human Resources Department in
selecting quality employees.
To assist us in this background check, please answer the following questionnaire.
Have you ever been convicted of a criminal act?
Yes
No
If yes, please explain:
Have you ever been convicted of child abuse or neglect?
Yes
No
If yes, please explain:
Have you ever been convicted of driving under the influence of drugs or
alcohol?
Yes
No
If yes, please explain:
Have you ever been convicted of possession, use or sale of narcotics?
Yes
No
If yes, please explain:
Have you ever worked for a DMH facility? (please check below)
Yes
No
Behavioral Health Programs
IDD Programs
Dates
Dates
North MS St Hospital
Boswell Regional Center
South MS St Hospital
Hudspeth Regional Center
East MS St Hospital
North MS Regional Center
MS State Hospital
South MS Regional Center
Central MS Residential Center
Ellisville State School
Specialized Treatment Facility
MS Adolescent Center
--- A Program of the Mississippi Department of Mental Health ---
HRD—021 Revised 07/18/2018
Top portion to be completed by applicant
Work Reference Inquiry
Applicant’s
Name
Dates
of
Employment
Company/Organization
Department
Phone
Number
Street No. or PO Box
City
State
Zip
Supervisor
Reason
for
Leaving
I hereby authorize the Specialized Treatment Facility to request verification of statements made by me on my employment
application and any other job-related information. I also give permission to the above company/organization to release
the information requested. I do hereby release the addressed individual, company, organization, and all individuals
connected therewith, including the Specialized Treatment Facility, from all liability for any damage whatsoever incurred
in furnishing such information.
Applicant’s
Signature
Date
To be completed by previous employer
Is the above information correct?
□
□
Yes
□
□
No If no, please note what information is incorrect.
What is your opinion
as to this person’s:
Above
Below
Average Average Average Unsatisfactory
Attendance
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Honesty
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Cooperation
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Dependability
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Initiative
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Courtesy
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Quality of work
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Ability to learn
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Ability to work with others
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Would you re-employ this person?
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Yes
□
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No
If no, please explain below.
Would you recommend that we employ this person?
□
□
Yes
□
□
No
If no, please explain below.
If you have a Drug/Alcohol Testing Policy, had this person ever tested positive for drugs and/or alcohol or violated
the drug/alcohol policies?
□
□
Yes
□
□
No
If yes, please explain below.
Supervisor’s Name (please print)
Title
SPECIALIZED TREATMENT FACILITY
14426 James Bond Road, Gulfport, MS 39503 Phone: (228) 328-6000 Fax: (228) 328-6035
Shannon Y. Bush, MPA, Program Director
--- A Program of the Mississippi Department of Mental Health ---
HRD—021 Revised 07/18/2018
Top portion to be completed by applicant
Work Reference Inquiry
Applicant’s
Name
Dates
of
Employment
Company/Organization
Department
Phone
Number
Street No. or PO Box
City
State
Zip
Supervisor
Reason
for
Leaving
I hereby authorize the Specialized Treatment Facility to request verification of statements made by me on my employment
application and any other job-related information. I also give permission to the above company/organization to release
the information requested. I do hereby release the addressed individual, company, organization, and all individuals
connected therewith, including the Specialized Treatment Facility, from all liability for any damage whatsoever incurred
in furnishing such information.
Applicant’s
Signature
Date
To be completed by previous employer
Is the above information correct?
□
□
Yes
□
□
No If no, please note what information is incorrect.
What is your opinion
as to this person’s:
Above
Below
Average Average Average Unsatisfactory
Attendance
□
□
□
□
□
□
□
□
Honesty
□
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□
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Cooperation
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Dependability
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Initiative
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Courtesy
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Quality of work
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Ability to learn
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Ability to work with others
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Would you re-employ this person?
□
□
Yes
□
□
No
If no, please explain below.
Would you recommend that we employ this person?
□
□
Yes
□
□
No
If no, please explain below.
If you have a Drug/Alcohol Testing Policy, had this person ever tested positive for drugs and/or alcohol or violated
the drug/alcohol policies?
□
□
Yes
□
□
No
If yes, please explain below.
Supervisor’s Name (please print)
Title
--- A Program of the Mississippi Department of Mental Health ---
HRD—021 Revised 07/18/2018
Top portion to be completed by applicant
Work Reference Inquiry
Applicant’s
Name
Dates
of
Employment
Company/Organization
Department
Phone
Number
Street No. or PO Box
City
State
Zip
Supervisor
Reason
for
Leaving
I hereby authorize the Specialized Treatment Facility to request verification of statements made by me on my employment
application and any other job-related information. I also give permission to the above company/organization to release
the information requested. I do hereby release the addressed individual, company, organization, and all individuals
connected therewith, including the Specialized Treatment Facility, from all liability for any damage whatsoever incurred
in furnishing such information.
Applicant’s
Signature
Date
To be completed by previous employer
Is the above information correct?
□
□
Yes
□
□
No If no, please note what information is incorrect.
What is your opinion
as to this person’s:
Above
Below
Average Average Average Unsatisfactory
Attendance
□
□
□
□
□
□
□
□
Honesty
□
□
□
□
□
□
□
□
Cooperation
□
□
□
□
□
□
□
□
Dependability
□
□
□
□
□
□
□
□
Initiative
□
□
□
□
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Courtesy
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Quality of work
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Ability to learn
□
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□
□
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Ability to work with others
□
□
□
□
□
□
□
□
Would you re-employ this person?
□
□
Yes
□
□
No
If no, please explain below.
Would you recommend that we employ this person?
□
□
Yes
□
□
No
If no, please explain below.
If you have a Drug/Alcohol Testing Policy, had this person ever tested positive for drugs and/or alcohol or violated
the drug/alcohol policies?
□
□
Yes
□
□
No
If yes, please explain below.
Supervisor’s Name (please print)
Title
Rev 2/2012
STATE OF MISSISSIPPI APPLICATION
Return Completed Application to:
Mississippi State Personnel Board
210 East Capitol Street, Suite 800
Jackson, MS 39201
www.mspb.ms.gov
For Staff/Official Use Only Received: __________________
Important! Please Read Before you begin the application process:
Applicants must complete and attach the “Supplemental Questions” page when applicable. This page is located on the MSPB
website Job Openings screen. Scroll down to the bottom of the screen and click the preferred job; when the description is displayed, click “Print Job Information.” Applications failing to include this page or lacking sufficient information will be returned to the applicant as invalid. Please ensure your application is received by the closing date as indicated on the job posting.
-TYPE OR PRINT IN BLACK INK-
JOB INFORMATION
POSITION #: POSITION TITLE:
PERSONAL INFORMATION
FIRST NAME MIDDLE INITIAL LAST NAME
ADDRESS
CITY STATE ZIP
HOME PHONE ALTERNATE PHONE
MONTH AND DATE OF BIRTH WHICH METHOD DO YOU PREFER TO BE NOTIFIED ABOUT YOUR APPLICATION STATUS? EMAIL OR PAPER
EMAIL ADDRESS
EDUCATION
WHAT IS YOUR HIGHEST LEVEL OF EDUCATION:
Some High School Some College Associate’s Degree Master’s Degree Doctorate Degree High School Technical College Bachelor’s Degree Specialist’s Degree
HIGH SCHOOL EDUCATION
DID YOU GRADUATE FROM HIGH SCHOOL/RECEIVE A G.E.D.? YES NO
IF NO, WHAT WAS THE HIGHEST GRADE LEVEL COMPLETED? 7 8 9 10 11 12
COLLEGE/UNIVERSITY EDUCATION
SCHOOL NAME DEGREE RECEIVED
DATES ATTENDED DID YOU GRADUATE?
YES NO
SEMESTER QUARTER # OF UNITS COMPLETED:
SCHOOL LOCATION (CITY/STATE) MAJOR
SCHOOL NAME DEGREE RECEIVED
DATES ATTENDED DID YOU GRADUATE?
YES NO
SEMESTER QUARTER # OF UNITS COMPLETED:
SCHOOL LOCATION (CITY/STATE) MAJOR
SCHOOL NAME DEGREE RECEIVED
DATES ATTENDED DID YOU GRADUATE?
YES NO
SEMESTER QUARTER # OF UNITS COMPLETED:
2
Rev 3/2012
TYPE DATE ISSUED (MONTH/YEAR) EXPIRATION DATE (MONTH/YEAR) LICENSE NUMBER ISSUING AGENCY SPECIALIZATION
TYPE DATE ISSUED (MONTH/YEAR) EXPIRATION DATE (MONTH/YEAR) LICENSE NUMBER ISSUING AGENCY SPECIALIZATION
WORK HISTORY
DATES
From To EMPLOYER POSITION TITLE
ADDRESS, CITY, STATE
PHONE NUMBER SUPERVISOR (NAME & TITLE)
HOURS PER WEEK SALARY MAY WE CONTACT THIS EMPLOYER?
YES NO DUTIES
DATES
From To EMPLOYER POSITION TITLE
ADDRESS, CITY, STATE
PHONE NUMBER SUPERVISOR (NAME & TITLE)
HOURS PER WEEK SALARY MAY WE CONTACT THIS EMPLOYER?
YES NO DUTIES
3
Rev 3/2012
WORK HISTORY
DATES
From To EMPLOYER POSITION TITLE
ADDRESS, CITY, STATE
PHONE NUMBER SUPERVISOR (NAME & TITLE)
HOURS PER WEEK SALARY MAY WE CONTACT THIS EMPLOYER?
YES NO DUTIES
DATES
From To EMPLOYER POSITION TITLE
ADDRESS, CITY, STATE
PHONE NUMBER SUPERVISOR (NAME & TITLE)
HOURS PER WEEK SALARY MAY WE CONTACT THIS EMPLOYER?
YES NO DUTIES
4
Rev 3/2012
___________________________________________________________ _____________________________________________________________ (AGENCY NAME) (CURRENT JOB TITLE)
3. HAVE YOU BEEN SEPRATED WITHIN THE LAST 12 MONTHS FROM THE STATE OF MS DUE TO A REDUCTION IN FORCE (RIF)? YES NO 4. IF YOU ANSWERED “YES” TO THE PREVIOUS QUESTION, INDICATE WHICH AGENCY, YOUR PREVIOUS JOB TITLE, AND THE DATE OF YOUR RIF SEPARATION. (IF YOU PREVIOUSLY INDICATED “NO”, PROCEED TO THE NEXT QUESTION.)
_______________________________________________ ______________________________________ ___________________________________ (AGENCY NAME) (PREVIOUS JOB TITLE) (DATE OF RIF)
5. ARE YOU A VETERAN OF THE ARMED FORCES? YES NO
(IF YOU INDICATED “YES”, YOU MUST ATTACH A COPY OF YOUR DD214 OR OTHER PROOF OF SERVICES.) 6. IF YOU ARE A VETERAN, WERE YOU DECLARED DISABLED? YES NO
7. ARE YOU AN ADULT MALE BORN ON OR AFTER JANUARY 1, 1960 WHO REGISTERED FOR SELECTIVE SERVICE BETWEEN THE AGES OF 18 AND 25? YES NO
TO MEET THE REQUIREMENTS OF FEDERAL REGULATIONS, MSPB NEEDS TO COLLECT INFORMATION ON THE QUESTIONS BELOW FOR REPORTING PURPOSES ONLY. THIS INFORMATION WILL NOT BE USED FOR MAKING EMPLOYMENT DECISIONS. (OPTIONAL)
8. INDICATE YOUR RACE AMERICAN INDIAN WHITE
HISPANIC BLACK ASIAN Other
9. INDICATE YOUR GENDER MALE
FEMALE
10. AGE GROUP: UNDER 18 18-25 26-39 40-54 55-69 70+
ADDITIONAL INFORMATION
Additional Information (other schools or training; special qualifications; honors and awards; etc.):
APPLICANT DECLARATIONS
By signing this application, I certify that all statements made herein and on any attached documents are true and complete to the best of my knowledge. I authorize the verification of this information by the Mississippi State Personnel Board and any agency considering me for employment. I know that any misrepresentation herein may lead to rejection of my application, removal of my name from the list of eligibles, and/or dismissal from state service. I understand that, as a condition of employment, I will be required to present documentation which verifies both my identity and my employment eligibility pursuant to federal immigration law.
X_________________________________________________________________ _________________________________________________
5
Rev 3/2012
SUPPLEMENTAL QUESTIONS
Applicants must complete and attach the “Supplemental Questions” page when applicable. This page is located on the
MSPB website Job Openings screen. Scroll down to the bottom of the screen and click the preferred job; when the description is displayed, click “Print Job Information.” Applications failing to include this page or lacking sufficient information will be returned to the applicant as invalid. Please ensure your application is received by the closing date as indicated on the job posting.
ADDITIONAL WORK HISTORY
JOB INFORMATION
JOB NUMBER: POSITION TITLE:
COLLEGE/UNIVERSITY EDUCATION
SCHOOL NAME DEGREE RECEIVED
DATES ATTENDED DID YOU GRADUATE?
YES NO # OF UNITS COMPLETED: SEMESTER QUARTER
SCHOOL LOCATION (CITY/STATE) MAJOR
SCHOOL NAME DEGREE RECEIVED
DATES ATTENDED DID YOU GRADUATE?
YES NO DATES ATTENDED
SCHOOL LOCATION (CITY/STATE) MAJOR
CERTIFICATES & LICENSES
TYPE DATE ISSUED (MONTH/YEAR) EXPIRATION DATE (MONTH/YEAR)
LICENSE NUMBER ISSUING AGENCY SPECIALIZATION
TYPE DATE ISSUED (MONTH/YEAR) EXPIRATION DATE (MONTH/YEAR)
LICENSE NUMBER ISSUING AGENCY SPECIALIZATION
WORK HISTORY
DATES
From To EMPLOYER POSITION TITLE
ADDRESS CITY STATE
COMPANY WEBSITE PHONE NUMBER SUPERVISOR (NAME & TITLE)
HOURS WORKED PER WEEK MONTHLY SALARY MAY WE CONTACT THIS EMPLOYER?
YES NO DUTIES
