Employment Application

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) 744-2447

Date(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

18 Years or Older?(Required)

Yes

Position applied for?(Required)

Date you can start?(Required)

MM slash DD slash YYYY

Current Employment Status(Required)

Are you currently employed?

Yes

May we inquire of your present employer?(Required)

Current Employer

Yes

Previous Employee of Robbinswood or Northcrest(Required)

Have you ever worked here?

Yes

If yes, when?

MM slash DD slash YYYY

Know employee of Robbinswood or Northcrest?(Required)

Do you know anyone who works here?

Yes

If yes, who?

Overtime Availability(Required)

Can you work overtime?

Yes

Shifts

For which shifts are you available?

Any Shift

1st

2nd

3rd

Grammar School (Name and location)

Did you graduate?

Yes

Degree / Major

High School (Name and location)

Did you graduate?

Yes

Degree / Major

College (Name and location)

Did you graduate?

Yes

Degree / Major

Trade, Business or Correspondence School (Name and location)

Did you graduate?

Yes

Degree / Major

Special skills?

Employment Record

Please list the most recent position first.

Employer 1

Name 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

Phone

Supervisor

Contact?

May we contact them?

Yes

Employer 2

Name 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

Phone

Supervisor

Contact?

May we contact them?

Yes

Employer 3

Name 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

Phone

Supervisor

Contact?

May we contact them?

Yes

Personal References

Reference 1

Name

Phone

Contact?

May we contact them?

Yes

Address

Street City State ZIP

Reference 2

Name

Phone

Contact?

May we contact them?

Yes

Address

Street City State ZIP

Emergency Contact - Name

Phone

Address

Street City State ZIP

Resume

Drop files here or

Max. file size: 256 MB, Max. files: 4.

(Optional) Upload resumé, letter of recommendation, or cover letter.

Approvals and Signature

I certify that the facts contained in this application are true and complete to the best of my knowledge and understand that, if employed, falsified statements on this application shall be grounds for dismissal.(Required)

I Agree

I authorize investigation of all statements contained therein and the employers listed above to give you any and all information concerning my previous employment and any pertinent information they may have, and release all parties in accordance with the employee right to know act, from all liability for any damage that may result from furnishing same to you.(Required)

I Agree

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 prior notice and without cause.(Required)

I Agree

Digital Signature

By typing my name I am providing my digital signature to certify that the information provided in this application is true and correct.

Date of Signature

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.

Hidden

Signature(Required)

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