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 ______On-call ______Summer only

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

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

5. 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: __________________________________________________________________________________

10. 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.

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

13. 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: ______________________________________________________________

15. 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: ______________

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

If yes, please indicate name and relationship: __________________________________________________________

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

seek:_________________________________________________________________________________________

_________________________________________________________________________________________________

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

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

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

20. 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)

__________________________________________________________________________________________________

21. 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 statements made on this application and applicable attachment(s) are true and that I have not withheld any facts or circumstances which would, if disclosed, affect my application unfavorably. I fully understand that the misrepresentation or omission of facts or circumstances will be sufficient cause for the cancellation of my consideration for employment or cause for dismissal if I have already been employed.

I authorize the investigation of all statements contained in this application and applicable attachment(s) and the further investigation of any information required to determine my qualifications for the position(s) for which I am applying. I authorize current and former employers, schools and other sources to release any information required by MMI to determine my qualifications for the positions 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.

I understand and agree that if an offer of employment is made, I may be required to submit to a physical examination by the organization's designated physician. I also understand and agree that if I should become employed by the organization I may be required to successfully complete a physical examination periodically thereafter in accordance with State and Federal Regulations. I also understand and agree that I may be required to submit to tests for alcohol and drug use prior to my employment and periodically thereafter.

I understand and agree that if I should become employed by MMI, my employment will be governed by the organization's personnel policies applicable to my position. I also understand and agree that MMI�s personnel policies may be changed by the organization at its discretion from time to time.

I understand and agree that this application is not intended to be a contract of employment. Should I become employed, my employment is not for any specified period of time and is terminable at the will of MMI without cause or notice. Modifications of the at-will employment relationship will not be valid unless reduced to writing and signed by myself and the organization's President.

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