APPLICATION (JOB) MMI – 2025 – Mid-Michigan Industries

Date *

Full Name *

Street Address / Apartment Number *

City, State and Zip Code *

Phone Number *

Alternate Phone Number

Email Address *

How did you hear about MMI (Check all that apply)

Current Employee
Advertisement
Other

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)

Full-time
Part-time
Seasonal

List any days or hours that you are unable to work

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

Are there any felony judgements or charges against you, pending included?

If yes, please describe

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 describe

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?

If yes, how many points?

Are you related to any board member, employee or client of MMI?

If yes, please indicate name and relationship

HIGH SCHOOL: Name, City and State

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 any trainings or certifications that you have had which may be relevent

Have you completed the Department of Mental Health curriculum for Direct Care Workers?

If yes, when?

What agency provided the training?

Are you certified in CPR and/or First Aid?

If yes, what is the 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)

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 #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 #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

PERSONAL REFERENCE #1: Name, relationship and phone number

PERSONAL REFERENCE #1: Address, City, State

PERSONAL REFERENCE #2: Name, relationship and phone number

PERSONAL REFERENCE #2: Address, City, State

PERSONAL REFERENCE #3: Name, relationship and phone number

PERSONAL REFERENCE #3: Address, City, State

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 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.

MMI is an Equal Opportunity Employer

All applicants will be considered for employment regardless of race, religion, sex, national origin, disability, or other legally protected status. If you need accommodations in completing this application, assistance will be available upon request.

e-Signature and Date

By signing you acknowledge understanding the Application Statements above

Comment

Quick Links

Explore Us

Recent Posts