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) 744-2447Date(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 Employment Status(Required)Are you currently employed? Yes No Current Employer(Required)May we inquire of your present employer? Yes No Previous Employee(Required)Have you ever worked here? Yes No If yes, when? MM slash DD slash YYYY Know employee?(Required)Do you know anyone who works here? Yes No If yes, who? Overtime(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 Date Start MM slash DD slash YYYY Date End MM slash DD slash YYYY Exact Reason for Leaving Address Street City State ZIP PhoneSupervisor Contact?May we contact them? Yes No Employer 2Name of Employer Date Start MM slash DD slash YYYY Date End MM slash DD slash YYYY Exact Reason for Leaving Address Street City State ZIP PhoneSupervisor Contact?May we contact them? Yes No Employer 3Name of Employer Date Start MM slash DD slash YYYY Date End MM slash DD slash YYYY 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 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. 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. 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. Signature
