Department Head 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)

Are you aware of any missed property tax payments? Do you know of any property tax liens ever filed against you?*

Have you ever been issued a notice of foreclosure? Have you ever been foreclosed on?*

Have you ever been issued a notice of eviction? Have you ever been evicted?*

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.*

What kind of activities were you involved in—publications, fraternity/sorority, school government, political organizations?*

Were you ever quoted in the school newspaper or other publications?*

Did you write a thesis? Is that thesis publicly available?*

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.*

Professional Licensure/Certification/Registrations

Have you ever applied for a Professional Licensure/Certification in any state or federal jurisdiction? If yes, state when and where and include the disposition for the application.

Filing Date	Name of Professional Certification/License	Jurisdiction	Disposition

Have you ever applied for a license which required that you possess good character and fitness? If yes, provide the type of license, the date of application, the licensing agency and its full address, the disposition of the application, and the current status of the license.*

With regard to any and all Licenses, Registrations, and Certificates, please list the name of the license and the license number you have obtained.*

Has a grievance or request for investigation ever been made against you as a holder of any office or professional license? If yes, explain the underlying circumstances including relevant dates and the disposition and provide the name and address of the authority possessing the record.*

Have you ever been reprimanded, admonished, censured or otherwise publicly or privately disciplined as the holder of any office or license? If yes, explain the underlying circumstances, including relevant dates and the disposition and provide the name and address of the authority possessing the record.*

Business Involvement

Have you ever held 10% or more of the ownership interest in any corporation, partnership, limited partnership, law practice, nonprofit corporation or association, or any other business entity? If yes, provide the following information:

Business Name	Address	Form of Business	Jurisdiction where Articles or Other Form Business Creation Documents are Filed

Have you ever been a general partner, operating member, officer or director of any partnership, limited liability company, corporation, or any other business entity? If yes, provide the following information:

Mo/Yr. to Mo/Yr.	Business Name	Position Held	Street Address	City	State	Zip Code

For each business identified, during the periods indicated, has the business been a defendant in any civil litigation, commercial arbitration, administrative proceeding, or criminal proceeding? If yes, briefly describe the underlying circumstances and disposition.*

Has any company with which you have been associated as an owner, officer, director, or partner, had any violations, or are there any investigations pending, involving state and federal-regulated matters such as MIOSHA, prevailing wage, environmental, workers compensation, unemployment compensation, taxation, etc. over the past 10 years? If yes, please explain.*

Financial Data

Do you have any debts which are more than 90 days past due? If yes, provide names and addresses of the creditor(s), the account number (s), the reason for the arrearage and the status of the obligations.*

Have you, in any fiduciary capacity, had a check returned for insufficient funds? If yes, provide the name and address of the bank returning check, the account number and describe the underlying circumstances.*

Have you ever failed to pay any federal or state income taxes such that you were assessed penalty interest by a taxing authority? If yes, please describe the circumstances*

Has any federal or state taxing authority ever notified you of an intent to file a lien against you for delinquent taxes? If yes, describe the circumstances and ultimate disposition of the matter or matters*

Have you ever been delinquent in the payment of any taxes, other than those described above, including without limitation, real property taxes, sales or use taxes, and employee withholding taxes for wages or other employee benefits? If yes, describe the circumstances and ultimate disposition of the matter or matters.*

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.*

Have you ever been delinquent in the payment of any child support obligation? If yes, provide the case caption, docket number and forum, amount of obligation date established current status of accounts, and date of each arrearage and describe the circumstances and resolution of each arrearage.*

Have you, a close relative, or an entity you operate ever declared bankruptcy or defaulted on a loan?

Yes
No

Civil Litigation

Have you ever been a party to any civil litigation, administrative proceeding, arbitration, probate matters, divorce proceeding and/or child custody matter? If yes, please provide the details.*

Have you ever been cited or held in contempt of court? If yes, explain the details.*

Have judicial enforcement proceedings ever been instituted against you alleging your nonperformance of any judgment, order, decision or award again you? If yes, please provide the details.*

Criminal History

With regard to the disclosure of criminal matters referenced in this section of the questionnaire, for each affirmative answer you must further disclose the date of arrest, underlying factual circumstances, name and address of arresting agency, nature of charges, name and address court and sentencing information, including the terms of probation and the probation offer’s identity, if applicable.

Have you ever been arrested or charged by federal, state or other law enforcement authorities for violation of any federal law, state law, county or municipal law, regulation or ordinance? If yes, please provide the details. You do not need to include traffic violations for which a fine of $150 or less was imposed or which involved less than two points.*

To the best of your knowledge if the investigation has been completed, have you ever been the subject of or interviewed in an investigation by any federal or state agency? If yes, explain.*

Have you ever agreed to testify or provide information or assistance to prosecuting officials in order to obtain immunity from criminal prosecution? If yes, please provide the details, including the names and addresses of the prosecuting officials.*

Have you ever been asked to testify in a grand jury proceeding in which you were informed that you were a subject? If yes, please provide the details.*

Do you have outstanding parking tickets from any jurisdiction that have remained unpaid for more than 30 days? If yes, please explain.*

Potential Conflicts of Interest

To your knowledge, does any organization to which you belong or have belonged exclude persons on the basis of race, color, religion, sex, national origin, disability, marital status, sexual preference, height, weight, arrests or veteran status? If yes, please identify the organization and describe the circumstances.*

Have you ever been publicly identified, in person or by organizational membership, with a particularly controversial national or local issue? If yes, please identify the organization and describe the circumstances.*

Do you know of any person or group of individuals who might take overt or covert steps to attack, even unfairly, your appointment? if so, please explain.*

Are you, your spouse or partner, or any member of your household or other close family members related to state government official or employee? If yes, please provide the details.*

During the past 5 years have you, your spouse or partner, any member of your household or other close family members, or any legal entity to which any of the aforementioned parties have been a beneficiary of, received any compensation or been involved in any financial transaction with the State of Michigan? Examples may include: government assistance programs, state procurement, and financial assistance. If yes, please explain.*

During the past 5 years, have you, your spouse or partner, any member of your household or other close family members received any compensation or been involved in any financial transaction with any state government official? If yes, please explain.*

Is the nature of employment for your spouse or partner, any member of your household or other close family members related in any way to the position to which you want to be appointed? If yes, please indicate the employer, the position and the length of time the position has been held.*

Briefly describe any lobbying activity during the past 10 years which you have been engaged in for the purpose of influencing the passage, defeat or modification of any legislative or administrative action.*

Briefly describe any lobbying activity during the past 10 years which you have been engaged in for the purpose of influencing the passage, defeat or modification of any legislative or administrative action.Briefly describe any interest which you, your spouse or partner, or any member of your household or other close family members who may have in any corporation, firm, partnership, or other business enterprise and any non-profit organization or other institution that is regulated by or receives direct financial benefit from any department or agency of the State of Michigan.*

Have you ever been sanctioned by any government body, with or without penalty, for activities deemed unethical, illegal, immoral etc.? If yes, please provide the details.*

Community, Civic or Professional Activity

List any associations or professional societies that you are or have been a member of and provide the titles and dates of any offices you have held in such groups*

List any civic and charitable organizations you have participated with, date of service, and indicate whether your served as an officer*

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.*

What websites feature you in a personal or professional capacity?*

RÉSUMÉ

Attach file

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