Personnel Application - Michigan Transition

Personal Information

Name*

First Middle Last

Email*

Have you ever used or have ever been known by, any other name than what you have given in this application? If yes, provide name and explain the circumstances

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Work Phone Number

Cell Phone Number*

Driver’s License Number*

Date of Birth*

Residence History

Begin with your current residence and list in reverse chronological order the address and city of each residence where you have lived in the past 15 years. Begin with your current residence. Include all addresses used for schooling, business or any other temporary purpose and the time period that those addresses were used.*

Mo/Yr. to Mo/Yr.	Address	City	State	Zip Code	Owned by you? (Y/N)

Educational Background

High Schools (Diploma or Equivalency)*

High Schools (Diploma or Equivalency)	School Name	Address	City	State	Zip Code	Degree Name

Colleges/Universities Attended*

High Schools (Diploma or Equivalency)	School Name	Address	City	State	Zip Code	Degree Name

Other Educational Institutions*

High Schools (Diploma or Equivalency)	School Name	Address	City	State	Zip Code	Degree Name

Since leaving high school have you, for other than academic reasons, ever been denied enrollment, disciplined, denied course credit, suspended, expelled or requested to terminate your enrollment, by any college, university, law school or other educational institution? If yes, provide the name and address of each institution, the dates, and explain the circumstances.*

Employment Background

List in reverse chronological order all part-time and full-time places of employment as well as periods of unemployment (beginning with your most recent employer) since receiving your undergraduate degree. Please provide a copy of your resume, including references.

Current Employment*

Mo/Yr. to Mo/Yr.	Employer	Address	City	State	Zip Code	Job Title	Telephone Number

Previous Employment*

Mo/Yr. to Mo/Yr.	Employer	Address	City	State	Zip Code	Job Title	Telephone Number

Have you ever been disciplined, discharged, or asked to resign from any position for involuntary reasons? If yes, explain the underlying circumstances and identify the employer or entity.*

Have you ever been a candidate for election to any public office? If yes, provide details, including whether successful or unsuccessful, title of office, location, and year of election.*

Have you ever been fined by the Secretary of State for a campaign finance violation? If yes, please explain.*

Military Service

Are you now or have you ever been a member of any military service, any reserve component or any national guard? If yes, provide the following information:

Mo/Yr. to Mo/Yr.	Branch of Service	Active or Reserve	Armed Services Identification Number

Have you ever been convicted in any court martial proceeding, including a proceeding under Article 15 of the Uniform Code of Military Justice? If yes, state the date, underlying circumstances, nature of the charge, result, and identify the military tribunal.*

Have you ever been discharged (other than honorably) from military service, or have you ever been administratively discharged? If yes, explain the nature of the discharge and the underlying circumstances.*

Have you ever been rejected for military service? If yes, state the date of rejection and provide the branch of service and the underlying circumstances.*

Have you ever requested or received a deferment or release from military service? If yes, please explain.*

Bonding

Have you ever made an application for or obtained employment that required bonding? If yes, please provide the following information:

Employer name	Full address	Mo/Yr. applied or dates employed	Nature of work

Have you ever been refused bonding? If yes, please provide the date of the application for the bond, the purpose for bonding, the name of the company refusing coverage and the reasons for refusal.*

Has anyone ever sought to cancel or collect upon a bond issued for you? If yes, identify the situation involved and explain the underlying circumstances.*

Additional Information

Have you ever been accused of discriminatory harassment related to sexual or other physical activity? If yes, please explain.*

Have you ever been accused of discriminatory harassment other than sexual harassment? If so, please explain.*

Has a subordinate employee or entity in which you hold supervisory/fiduciary responsibility ever been accused of sexual harassment, sexual misconduct, hostile work environment, or inappropriate behavior related to sexual or other physical activity? If yes, please explain*

Have you ever been treated for abuse (i.e. drug, alcohol, gambling)? If yes, please provide the details.*

Digital/Social Media

Please list all known social media accounts affiliated with you and authorized by you.*

Please list all blogs, podcasts, YouTube channels or other digital content with which you are affiliated as a content provider, writer, producer, editor, founder, owner, distributor or host.*

Résumé

Attach résumé

Max. file size: 200 MB.

Notice and authorization of background investigation

This notice is being provided to advise you that Michigan Transition may obtain information about you from a consumer reporting agency in order to make decisions regarding your employment. Thus, you may be the subject of one or more “consumer reports” that may include information about your character, general reputation, personal characteristics, and/or mode of living. These reports may be obtained at any time after receipt of your authorization and, if you are hired, throughout your employment.

Acknowledgement and Authorization

I acknowledge receipt of this Notice Regarding Background Investigation and a Summary of Your Rights Under the Fair Credit Reporting Act and certify that I have read and understand both documents I hearby authorize Employer to obtain one or more “consumer reports” at any time after receipt of this authorization and, if I am hired, throughout my employment. I agree that a facsimile, electronic, or photographic copy of this Acknowledgement and Authorization shall be as valid as the original.

I agree and authorize

I hereby solemnly swear that the foregoing answers provided are true and accurate to the best of my knowledge and belief.

Date

Name

First Last

Signature*

Equal Opportunity Employer

APPLY FOR PERSONNEL POSITION

Personal Information

Residence History

Educational Background

Employment Background

Military Service

Bonding

Additional Information

Digital/Social Media

Résumé

Notice and authorization of background investigation

I hereby solemnly swear that the foregoing answers provided are true and accurate to the best of my knowledge and belief.

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