JOB APPLICATION

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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. MMI is an Equal Opportunity Employer

Please complete the form below and click the “Submit Application” button

 

MMI Job Application
Date:*
Full Name*
Address*
Phone*
Alternate Phone
E-mail:*
How did you hear about MMI? (Check all that apply)
Please provide the name of the Employee, Advertisement or Other way you heard about MMI
What position are you applying for?
Would you prefer: (Check all that apply)
List any days or hours that you are unable to work
In which county(ies) are you able to work? (Check all that apply)
Are you currently employed?
If yes, where?
Date available for work?
Were you previously employed by MMI?
If yes, under what name?
If yes, provide start and end dates
Have you ever been convicted of a crime?
If yes, please describe
Are there any felony charges pending against you?
If yes, please describe the felony charges pending against you
Are you legally eligible for employment in the United States? (Proof of citizenship or immigration status will be required upon employment)
If you are under the age of 18, can you provide a work permit?
Have you ever been discharged or asked to resign from a job?
If yes, please explain.
During the past 5 years, were you ever unemployed for longer than 6 months?
If yes, please explain
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?
Are you related to any board member, employee or client of MMI?
If yes, please indicate name and relationship.

EDUCATION

HIGH SCHOOL: Name, City and State
HIGH SCHOOL: Course of Study
HIGH SCHOOL: Number of years completed
HIGH SCHOOL: Did you graduate?
COLLEGE: Name, City and State
COLLEGE: Course of Study
COLLEGE: Number of years completed
COLLEGE: Did you graduate?
OTHER EDUCATION: Name, City and State
OTHER EDUCATION: Course of Study
OTHER EDUCATION: Number of years completed
OTHER EDUCATION: Did you graduate?
Please list the above information for additional places of Education, if applicable

TRAINING & CERTIFICATIONS

Please list any trainings or certifications that you have had which may be relevant
Have you completed the Department of Mental Health curriculum for Direct Care Workers?
What agency provided the training?
Are you certified in First Aid?
If yes, what is the First Aid Certification expiration date?
Are you certified in CPR?
If yes, what is the CPR Certification expiration date?
Please list any volunteer experiences that you have had
Please list any professional memberships that you belong to: (Exclude those which may disclose your race, color, religion, or national origin)
Please indicate your proficiency with any work-related equipment or office machines.

EMPLOYMENT

EMPLOYER #1: Company Name
EMPLOYER #1: Company Phone Number
EMPLOYER #1: Address, City, State, Zip Code
EMPLOYER #1: Dates of Employment (From/To)
EMPLOYER #1: Position Title
EMPLOYER #1: Job Duties
EMPLOYER #1: Supervisor's Name
EMPLOYER #1: May we contact this employer?
EMPLOYER #1: Reason for Leaving?
EMPLOYER #1: Salary & Wages (Starting/Ending)
EMPLOYER #2: Company Name
EMPLOYER #2: Company Phone Number
EMPLOYER #2: Address, City, State, Zip Code
EMPLOYER #2: Dates of Employment (From/To)
EMPLOYER #2: Position Title
EMPLOYER #2: Job Duties
EMPLOYER #2: Supervisor's Name
EMPLOYER #2: May we contact this employer?
EMPLOYER #2: Reason for Leaving?
EMPLOYER #2: Salary & Wages (Starting/Ending)
EMPLOYER #3: Company Name
EMPLOYER #3: Company Phone Number
EMPLOYER #3: Address, City, State, Zip Code
EMPLOYER #3: Dates of Employment (From/To)
EMPLOYER #3: Position Title
EMPLOYER #3: Job Duties
EMPLOYER #3: Supervisor's Name
EMPLOYER #3: May we contact this employer?
EMPLOYER #3: Reason for Leaving?
EMPLOYER #3: Salary & Wages (Starting/Ending)
EMPLOYER #4: Company Name
EMPLOYER #4: Company Phone Number
EMPLOYER #4: Address, City, State, Zip Code
EMPLOYER #4: Dates of Employment (From/To)
EMPLOYER #4: Position Title
EMPLOYER #4: Job Duties
EMPLOYER #4: Supervisor's Name
EMPLOYER #4: May we contact this employer?
EMPLOYER #4: Reason for Leaving?
EMPLOYER #4: Salary & Wages (Starting/Ending)

PERSONAL REFERENCES

REFERENCE #1: Name, Relationship, and Phone Number
REFERENCE #1: Address, City, State
REFERENCE #2: Name, Relationship, and Phone Number
REFERENCE #2: Address, City, State
REFERENCE #3: Name, Relationship, and Phone Number
REFERENCE #3: Address, City, State
e-Signature | By signing below you acknowledge understanding the Application Statement below.*
Word Verification:



APPLICATION STATEMENT

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 designed 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.


Mid-Michigan Industries
2426 Parkway Drive
Mt. Pleasant, MI 48858
Phone: 989.773.6918
Fax: 989.773.1317
Email: hr@mmionline.com
Michigan Relay Center: 800.649.3777 Voice & TDD