Employment Application Frame

Name: _______________________________________________________________ Date of application: ______________

Address: _____________________________________________________________________________________________

Phone: (_____) __________________ Alternate Phone: (_____) ________________ E-mail: ________________________

HOW DID YOU LEARN ABOUT US? (Please check one)

_____ Current Employee (List employee's name)_______________________________________________

_____ Advertisement (Indicate where you saw the ad)____________________________________________

_____ Other: (Please describe)______________________________________________________________

1. What position(s) are you applying for? _______________________________________________________________

2. Would you prefer: _______Full-time _______ Part-time ______Temporary ______Contingent

3. Can you perform the essential functions of the position for which you are applying, with reasonable accommodation if needed?

4. List any days or hours that you are NOT willing to work: _______________________________________________

5. In which county(s) are you willing to work? Clare ___ Isabella ___ Gratiot ___ Montcalm ___ Other______________

6. Are you employed now? _______ If yes, where? ___________________ Date available for work: ______________

If yes, under what name? ________________________________ Start date: ___________ End date: ____________

If yes, under what name? ____________________________________________ When? _______________________

If yes, describe: __________________________________________________________________________________

11. Are you legally eligible for employment in the United States? ______yes ______no

All applicants will be considered for employment without regard to race, religion, color, sex, national origin, non-job-related medical condition or handicap, or other legally protected status. Auxiliary aids and services for completing this application are available to persons with disabilities upon request.

We are an Equal Opportunity Employer.

13. Are you currently on lay-off status and subject to recall? ______yes ______no

14. Have you ever been discharged or asked to resign from a job? ______yes ______no

(Please include any discharges that were subsequently converted to resignations)

If yes, please explain: _____________________________________________________________________________

______yes ______no If yes, explain: ______________________________________________________________

16. If the position for which you are applying requires driving on behalf of the agency, we must conduct a check of your

driving record. Do you currently have any points on your license? ____yes ____no # of points: ______________

17. Are you related to any board member, employee or client of MMI? ______yes ______no

If yes, please indicate name and relationship: __________________________________________________________

18. Please list additional training or certifications that you have that would be relevant to the position you

seek:_________________________________________________________________________________________

_________________________________________________________________________________________________

19. Have you completed the Dept. of Mental Health curriculum for Direct Care Workers? _____yes _____no

If yes, when? ________________ What agency provided the training? ___________________________________

20. Are you certified in First Aid or CPR? _____yes _____no Expiration dates: First Aid__________ CPR____________

21. Please list any volunteer experience or professional memberships that would be relevant to the job:

(Exclude those which may disclose your race, color, religion or national origin)

__________________________________________________________________________________________________

22. Please indicate your proficiency with any work-related equipment or office machines: _________________________

__________________________________________________________________________________________________

EMPLOYMENT HISTORY: (Start with most recent employer; include military experience)

PERSONAL REFERENCES: (List three people not related to you who are familiar with the quality of your work and whom you have known for at least a year)

Please read the statements below and sign to confirm your understanding. Applications will not be considered without signature.

I certify that all answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision. I understand and agree that if an offer of employment is made, I will be required to submit to MMIs pre-employment screening process, drug and background screening, and that my employment offer is contingent upon successful completion, as well as anytime during employment. . Any information discovered about me during any investigation which is deemed by the Company to be unsatisfactory shall constitute grounds for immediate discharge, regardless of when discovered.

I authorize current and former employers, references, schools and other sources to release any information required by MMI to determine my qualifications for the position (s) for which I am applying and hereby release all individuals and organizations for any liability or damages on account of having furnished such information. I waive any right under Public Act 397 or 1978 to receive any written notice from the organization, former employers and other sources that such information has been released.

In the event of employment, I understand that false or misleading information or omission of information given in my application or interview(s) (including failure to disclose relevant information) may result in discharge whenever discovered. I understand if I am employed that I will be on a Probationary/Introductory ninety (90) days status. I understand that my employment is at-will and that I or the Company have the right to terminate my employment at any time, with or without reason during and following the ninety (90) day period.

I understand and agree that if I should become employed by MMI, my employment will be governed by the organization's policies. I also understand and agree that MMI�s personnel policies may be changed by the organization at its discretion as deemed necessary.

I understand and agree that this application is not intended to be a contract of employment.

Signature of Applicant: ___________________________________________________________ Date: ________________

SCHOOL	NAME OF SCHOOL CITY AND STATE	COURSE OF STUDY	# OF YEARS COMPLETED	DID YOU GRADUATE?
GRADUATE PROGRAM
COLLEGE
BUSINESS/ TECHNICAL
HIGH SCHOOL

Name	Address	Relationship	Phone