Application for Employment - Central State Community Services Michigan

Application for Employment

First Name *

Last Name *

Any other last names used?

Preferred first name

Phone Number *

Email *

How did you hear about Central State Community Services? *

If Friend/Family, who do we thank for the referral?

Are you related by blood, marriage or adoption to anyone who works at Central State? *

What county are you interested in working in? *

Do you have a current, valid, unrestricted State of Michigan Driver's License? *

Have you ever worked for Central State before? *

What date(s)?

Have you ever pled guilty or no contendre to, been convicted of, received a deferred/suspended sentence, or been placed on probation for a criminal offense (other than minor traffic violations) *

If yes, please explain-

Are you authorized to work in the U.S.? *

(Michigan Central State will verify your eligibility to work in the United States via participation in the DHS/SSA E-Verify program.)

Position Desired *

Date available to start:

Work History

Are you currently employed? *

If yes, may we contact your present employer? *

What is the name of the company?

What is the name of your current supervisor?

Phone/ Email Address

Previous Employment Company Name *

Phone Number/Email Address

Previous Employment Company Name

Phone Number/ Email Address

Education History

What is your highest level of education? *

What is the name of the high school you graduated from? (You will be required to provide a copy of your diploma or GED certificate).

List any certifications you have:

What is the name of the college/university you attended?

References/ Emergency Contact

Three references are required

First Name (Contact #1) *

Email *

How long have you known this person?

Last Name

Phone Number

Relationship *

First Name (Contact #2) *

Email *

How long have you known this person?

Last Name *

Phone Number

Relationship *

First Name (Contact #3) *

Last Name *

Email *

Phone Number

How long have you known this person?

Relationship *

Who may we contact in case of an emergency? (Name) *

Phone number of emergency contact: *

Paragraph Text

By State policy, we are required to verify your employment with all former employers. Please thoroughly read and complete the attached Employment Application Supplement. Failure to comply could affect your status in the position selection process. I certify that the facts contained in this application are true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and the references listed to give you all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and the release of all parties from all liability for any damage that may result from furnishing same to you. Per State policy, I acknowledge that I have received for my information a copy of the DDS 59 (Rights and Responsibilities of Community Service Worker in an Investigation of Maltreatment). I understand and agree that, if hired, my employment is for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without any prior notice.

Signature *

Today's Date *

Thank you for your interest in working at Central State Community Services! When your application is received, someone will reach out to you soon. Please call (989) 631-6691 if you have any questions.

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