The following information is requested in order to help us make the possible placement within the company. All portions of this application pertaining to you must be completed. We appreciate the time you spend in filling in this application form. The company, in accordance with state and federal laws, does not discriminate on the basis of age, race, religion, color, sex. national origin, marital status, physical or mental handicap, height, weight or arrest record. Grand Haven Campus: 1125 Robbins Road, Grand Haven, MI 49417- (616) 842-1900 Northcrest Campus: 2650 Rudiman Drive, North Muskegon, MI 49445 - (231) 744-2447Date(Required) MM slash DD slash YYYY Name(Required) First Middle Last Address(Required) Street City State ZIP Phone Number(Required)Email(Required) U.S. Citizen(Required)Are you either a U.S. Citizen or an alien authorized to work in the United States? Yes No 18 Years or Older?(Required) Yes No Position applied for?(Required) Date you can start?(Required) MM slash DD slash YYYY Current Employment Status(Required)Are you currently employed? Yes No May we inquire of your present employer?(Required)Current Employer Yes No Previous Employee of Robbinswood or Northcrest(Required)Have you ever worked here? Yes No If yes, when? MM slash DD slash YYYY Know employee of Robbinswood or Northcrest?(Required)Do you know anyone who works here? Yes No If yes, who? Overtime Availability(Required)Can you work overtime? Yes No ShiftsFor which shifts are you available? Any Shift 1st 2nd 3rd Grammar School (Name and location) Did you graduate? Yes No Degree / Major High School (Name and location) Did you graduate? Yes No Degree / Major College (Name and location) Did you graduate? Yes No Degree / Major Trade, Business or Correspondence School (Name and location) Did you graduate? Yes No Degree / Major Special skills? Employment RecordPlease list the most recent position first.Employer 1Name of Employer Last Position Held Date Start MM slash DD slash YYYY Date End MM slash DD slash YYYY Last Hourly Wage or Annual Salary Exact Reason for Leaving Address Street City State ZIP PhoneSupervisor Contact?May we contact them? Yes No Employer 2Name of Employer Last Position Held Date Start MM slash DD slash YYYY Date End MM slash DD slash YYYY Last Hourly Wage or Annual Salary Exact Reason for Leaving Address Street City State ZIP PhoneSupervisor Contact?May we contact them? Yes No Employer 3Name of Employer Last Position Held Date Start MM slash DD slash YYYY Date End MM slash DD slash YYYY Last Hourly Wage or Annual Salary Exact Reason for Leaving Address Street City State ZIP PhoneSupervisor Contact?May we contact them? Yes No Personal ReferencesReference 1Name PhoneContact?May we contact them? Yes No Address Street City State ZIP Reference 2Name PhoneContact?May we contact them? Yes No Address Street City State ZIP Emergency Contact - Name PhoneAddress Street City State ZIP Resume Drop files here or Select files Max. file size: 512 MB, Max. files: 4. (Optional) Upload resumé, letter of recommendation, or cover letter.I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if hired, any falsified statements on this application shall be grounds for dismissal. I authorize investigation of all statements contained herein and consent for all employers, education institutions and reference persons listed above to release any and all information related to my previous employment or education pertinent to this position. Furthermore I waive all written notice from all previous employers and release all parties in accordance with the employer right to know act, from all liability for any liability or damage that may result from furnishing such information to Robbinswood. I understand if Robbinswood selects me for employment consideration that as a condition of employment with Robbinswood I will be required to complete and be deemed eligible for employment by the State of Michigan through the Michigan Workforce Background Check & fingerprinting process. Furthermore I understand all offers of employment are subject to completing and passing a “staff fitness for work evaluation” and a negative TB test result. I understand and agree that, if hired, my employment is at-will, for no definite period and may, regardless of the date of payment of my wages and salary, be terminated at any time without prior notice and without cause. Signature
