Employment Application





 
*
First Name:
 
*
Last Name:
 
Middle Name:
 
*
Email Address:
 

*
Permanent Address:
 
*
City:
 
*
State:
 
*
Zip:
 

Home Phone:
 
Cell Phone:
 
Best time to call?  
Date Available for Work?
 

Are you applying for: "Part-time / Full-time"?
 
Location are you applying for:

 Boyne City Big Rapids Cheboygan Gladwin Grayling Gaylord Houghton Lake Roscommon West Branch Newaygo

Shift Preference: “Evenings, Nights, Weekends, Any”?
 
Are you a US citizen / legal alien authorized to work in the US?
 
 Yes No
Are you 18 years or older?
 
 Yes No

Position Applying for:
 
Desired Salary:
 
Relatives or Friends employed at this facility?    Yes No
If yes, who?  
How were you referred to this facility?
 
Have you ever been employed by this facility?
 
 Yes No
Have you ever been guilty of, or plead guilty to a crime? (excluding misdemeanor traffic violations )
 
 Yes No
Please explain if YES:
 
Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this or any other state of the United States?
 
 Yes No
Please explain if YES:
 

EDUCATION (Name and address of school. Course of Study: Graduate? Degree? License?)
High School:
 
College:
 
College:
 
Other:
 
Other:
 

Professional Licenses:
 
 Yes No
List any other Professional Certifications. Note the "Date Certified" and "State Certified In":
 
Currently licensed:
 
 Yes No
Eligible for License:
 
 Yes No
Currently Registered:
 
 Yes No
Has your license or registration ever been suspended, revoked or on probation?
 
 Yes No
Please explain if YES:
 

Previous Experience:
 
 
Employer Name
 
Job Title:
 
Date from/to:
 
Phone:
 
Address:
 
Duties:
 
Supervisor’s Name:
 
Reason for leaving:
 
Rate of pay at end of employment?  
 
Employer Name
 
Job Title:
 
Date from/to:
 
Phone:
 
Address:
 
Duties:
 
Supervisor’s Name:
 
Reason for leaving:
 
Rate of pay at end of employment?  
 
Employer Name
 
Job Title:
 
Date from/to:
 
Phone:
 
Address:
 
Duties:
 
Supervisor’s Name:
 
Reason for leaving:
 
Rate of pay at end of employment?  
 
Please identify and explain any gaps in employment longer than 3 (three) months:
 
Occupational Goal:
 
 
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