Name:*

First

Last

Address:*

Street Address City State / Province / Region Postal / Zip Code Country

Phone:*

Email:*

If hired can you provide proof that you are legally able to work in the United States?*

Yes

No

Are you 18 or older?*

Yes

No

Have you ever served in the U.S. Military?*

Yes

No

If you were referred by an employee please give their name:

Have you ever been convicted of a criminal offense (felony or misdemeanor)?: *

Yes

No

If yes, please state nature of offense(s), date(s), city, state and disposition:

What days and hours are you available to work? A minimum of every other weekend is required *

When are you available to begin work?*

Are you available for overtime?*

Yes

No

Do you have access to a reliable vehicle with current license, registration, and insurance?*

Yes

No

1/6

List all languages you speak fluently:

Do you have any skills, training or experience that would enable you to succeed at this job such as medical training or experience working with individuals with disabilities?

Education

Have you completed high school, GED, or equivalent?*

Yes

No

If you have completed any junior college, trade school, tech school, or university please list below:

Universities/Schools:

School Name and Location

Number of Years Completed

Graduated? Yes/No

Degree or Diploma Type (e.g. associates, bachelors)

Field of Study

School/University

Please account for all employment within the last five years, beginning with your current or most recent employer. In addition, please indicate any other experience that you believe in relevant to the position for which you are applying.

Positions Held

Company Name:

Dates Employed (put in today's date for end date if you are currently employed there)

Position Held:

Salary range:

From

To

Company Address:

Street Address City State / Province / Region Postal / Zip Code Country

Specific Job Duties:

Supervisor Name:

May we contact this employer?

Yes

No

(2) Company Name:

(2) Position Held:

(2) Dates Employed (put in today's date for end date if you are currently employed there)

(2) Specific Job Duties:

(2) Salary range:

From

To

(2) Company Address:

Street Address City State / Province / Region Postal / Zip Code Country

(2) Company Phone:

(2) Supervisor Name:

(2) May we contact this employer?

Yes

No

Please list two (2) persons NOT related to you who have known you for at least five (5) years.

Reference:*

First

Last

Phone*

Email*

Relationship to you (teacher, supervisor, etc.)*

(2) Reference:*

First

Last

(2) Phone*

(2) Email*

(2) Relationship to you (teacher, supervisor, etc.)*

Upload Resume (optional)

Initial each item after reading.

1. The information that I have provided on this application is accurate to the best of my knowledge and may be verified by Independent Community Living or its agents.

1. Initial:*

2. I authorize all the schools, persons, and organizations named in this application to provide any relevant information in their possession or knowledge to the agents of Independent Community Living, for use in deciding whether or not to offer me employment and specifically waive any required written notification. I hereby release Independent Community Living, my former employers and all other persons from any and all claims, demands, or liabilities arising out of or in any way related to such injury or disclosure.

2. Initial:*

3. I understand that Independent Community Living is committed to maintaining a drug and alcohol free work place. Accordingly, I may be subject to a pre-employment blood test, urinalysis or other drug/alcohol screening. I further understand that if employed, I may be subjest to such a drug and alcohol screening if Independent Community Living has reasonable suspicion to believe that I am under the influence of a drug or alcohol. My consent to submit to such a test is required as a condition or employment and my refusal to consent shall result in a refusal to hire or, if already employed, termination.

3. Initial:*

4. I understand and agree that any misrepresentation or omission of facts in this application will be justification for refusal or termination of employment, regardless of the time elapsed before discovery.

4. Initial:*

5. I understand and agree that the employment for which I am making application is, and is intern to be, at-will, and such employment may be terminated at any time with or without cause, without prior notice, by either myself, or Independent Community Living. There will be no agreement, express or implied between Independent Community Living and me for any specific period of employment.

5. Initial:*

My signature and information in the spaces below signifies that I have completed the entire application to the best of my ability and have carefully read the foregoing six (6) statements.

Signature:*

Date*

1. By this document Independent Community Living discloses that a consumer report may be obtained for employment purposes as part of the pre-screening background check and at any time during your employment or affiliation.

2.This shall authorize the procurement of a consumer report by a credit reporting agency or other sources as part of the pre-screening background investigation. If accepted, this authorization shall remain on file and shall serve as an ongoing authorization for the named employer or its associates or other sources to procure consumer reports at any time during my affiliation or employment period.3. I authorize the procurement or an investigative consumer report and understand that it may contain information about my employment and educational background, criminal history, credit, workers comp claims, mode of living, character and personal reputation. I also understand you may make use of the internet including social networking sites. I understand that I have the right to obtain additional disclosure as to the nature and scope of the investigation upon written request within a reasonable period of time and to obtain a copy of the report upon request. This authorization, in original or copy form, shall be valid for this and any future reports or updates that may be requested.4. In connection with this request, I authorize all corporations, companies, former employers, supervisors, credit agencies, vehicle bureaus, and persons to release information they may have about me to the person or company with which this form has been filed if required, or their agent. I further authorize you to secure an investigative consumer report at any time, and legally permissible and legitimate business need for the information requested.I release and hold harmless all parties involved from any and all liability for damages arising from requesting, procuring, or furnishing the requested information except with respect to a violation of the Act. I authorize the employer and its agent/credit reporting agency and all associated entities and its clients to receive any criminal history information or credit report pertaining to me in the files of any state or local criminal justice agency.5. I authorize Community Mental Health for Central Michigan (CMHCM) and CMHCM Office of Recipient Rights to disclose to Independent Community Living any and all information in possession of CMHCM regarding any violation of recipients' rights committed by me.

Name*

First

Last

Any other names used:

Social Security Number:*

Date of birth:*

Driver's License Number:*

Current Address"*

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Skills

Education

Employment History

Positions Held

References

Applicant's Statement

Disclosure/Release/Authorization