VOLUNTEER APPLICATION

Please print legibly and complete all sections of the application:

Name:______________________________________________________________  Date of application:____________

            (Last)                                                          (First)                                         (Middle)            

 Address:__________________________________________________________________________________________

                 (No. and  Street)                                                  (City)                                  (State)                        (Zip)

 Phone:  (_____) __________________  or  (_____)___________________    Email: ___________________________

  1.  What days and/or hours are you available to volunteer:  _________________________________________________

  2.  Please explain why you want to perform volunteer work at MMI and the type of work you would like to perform:  

      ____________________________________________________________________________________________

____________________________________________________________________________________________

 3.  Have you ever been convicted of a crime?   ______yes  ______no

       If yes, describe:_______________________________________________________________________________

 4.  Are there any felony charges pending against you? ______yes  ______no

       If yes, describe:_______________________________________________________________________________

 5.   Are you 18 years of age or older? ______yes    ______no

 EDUCATION AND TRAINING:

 6.  Describe specialized training/skills or extra curricular activities that you have had that would be relevant to this position

     (Please include any experience that you have had with individuals with disabilities or other barriers to employment):

 __________________________________________________________________________________________________

 __________________________________________________________________________________________________

 __________________________________________________________________________________

 Application continued on the back of this page.

EMPLOYMENT/PERSONAL REFERENCES:  List two 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.

STATEMENT

As a prospective volunteer of MMI, I understand that it is the agency's policy to secure criminal background, motor vehicle, and primary verification checks as part of the Volunteer Screening process.  I understand that information will be obtained (under the provisions of the Michigan Freedom of Information Act, P.A. 442 of 1976) from the Criminal Justice Information Center, the Michigan Public Sex Offender's Registry, the Secretary of State, or any city, state or federal agency, department or bureau.

I authorize MMI to utilize the following information for the sole purpose of obtaining a conviction only criminal history and/or a copy of my motor vehicle record.

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 volunteer employment or cause for dismissal if I have already been accepted as a volunteer.

            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 Mid-Michigan Industries, Inc. 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 this volunteer application is not intended to be a contract of employment.

     Signature:___________________________________________________________            Date:________________

 MMI

2426 Parkway Drive

Mt. Pleasant, MI 48858

Phone:  (517)773-6918

Fax:  (517)773-1317

E-Mail:  hr@MMIonline.com

Michigan Relay Center:  (800)649-3777 Voice & TDD