Do you have the legal right to remain and work in the U.S.? (Proof will be required, if hired) *
(This question only applies to positions that require business driving)
(List most recent schools first)
Previous 10 Years of Employment *
(List all relevant past employers starting with the most recent)
(List at least three (3) business or educational references, excluding friends or relatives)
I acknowledge and certify that the information contained in this application (and resume, if applicable) is true and complete. I understand that falsification or omission of relevant facts in my application, resume, other materials provided, during my interview, or during my employment, if hired, in any detail, is grounds for disqualification from further consideration or for discipline or dismissal from employment in accordance with Northeast Michigan Community Mental Health Authority’s (the Authority) policies. I agree to conform to the Authority’s policies, procedures, and work rules. I understand that my employment relationship with the Authority, if hired, is “at-will” (unless otherwise indicated in writing that I am subject to a just cause employment agreement), and that I or the Authority may terminate my employment with or without cause, and with or without notice, at any time. I further understand that no agent or representative of the Authority has any authorization to enter into a contract of employment with me or my representative except for the Authority’s Executive Director or Board President and that the Authority’s Board President or the Executive Director, or their designee, must sign any such agreement. I further acknowledge and agree that any dispute or claim against the Authority or any of its officers, board members, managers or employees that I may have that arises from my application for employment, my actual employment or separation therefrom must be filed within 180 calendar days, or less if based on a lesser limitations period, of the occurrence giving rise to the dispute or I will waive my right to pursue the claim and any damages or remedy. I understand that I must file any such claim in Alpena County, Michigan or in the U.S. Federal District Court for the Eastern District of Michigan, Northern Division or I will forfeit my claims. Filing in another jurisdiction will not be valid or toll the above limitations period.
I acknowledge that any offer of employment I may receive from the Authority is contingent on the results of a reference and background check. Therefore, I authorize the Authority to: (1) investigate the truthfulness of all statements made on this application, or my resume; (2) contact my former employers and other listed references or any other persons who can verify information (including law enforcement agencies); and (3) discuss results of any investigation with other Authority employees involved in the hiring process. In addition, I give my consent for all contacted persons, including former employers, to provide information concerning this application and I release each such person from liability for providing information to the Authority. I waive any written notice for the release of any information, including my discipline history, which may be required under state or federal law.
I hereby give my consent for the Authority through an authorized agent to collect my urine, saliva, blood, or hair samples for the purposes of testing for the presence, and my use of, alcohol, drugs, or other controlled substances. I hereby specifically release Northeast Michigan Community Mental Health Authority and its authorized collection/testing agent from any liability whatsoever, including attorneys’ fees, from any liability resulting from the collection or testing process or from the tests’ results. I further understand that should I receive an offer of employment, it may be conditioned upon my undergoing and successfully passing a job-related medical examination. I also understand and agree that, if employed, I may be required to submit to an alcohol or drug test, or job-related medical examination at any time at the discretion of the Authority. I hereby consent to having the results of any such alcohol or drug test or job-related medical examination disclosed to the Authority’s representative. I also acknowledge that any offer of employment that I receive is contingent upon the satisfactory results of my alcohol and drug test and my job-related medical examination finding me able to perform the essential functions of the job offered with or without reasonable accommodation. I understand that a positive drug test result, a refusal to submit a requested sample for testing, or a refusal to authorize such testing may result in the Authority withdrawing any offer of employment made to me, or result in my immediate discipline or dismissal.
Should I have a legally protected physical or mental disability that affects my ability to perform the job that I seek, I understand that I may request that the Authority provide a reasonable accommodation for it. I am aware that under Michigan’s Persons with Disabilities Civil Rights Act I must make any request for accommodation immediately known in writing and no later than 182 days after the date that I know, or reasonably should have known, of my need for an accommodation. I understand; however, that my failure to request an accommodation under Michigan law does not waive any right that I may have to request an accommodation under the federal Americans with Disabilities Act of 1990, which does not need to be in writing.
I certify that the above information that I have provided in this application is true and correct to the best of my knowledge and information and that I am voluntarily applying for employment and executing this application.
Disclosures and Authorizations *
DISCLOSURE TO APPLICANT/EMPLOYEE
Northeast Michigan Community Mental Health Authority (NEMCMHA or the Authority) may obtain a consumer report on you for employment purposes. It may be an “investigative consumer report” that includes information as to your character, general reputation, personal characteristics, and mode of living. Should the Authority request such an investigative consumer report, you have the right to request additional disclosures, including the nature and scope of the report that may include personal interviews. Moreover, the Authority will not discriminate against any applicant or employee, or otherwise misuse the information in violation of federal or state equal opportunity laws or regulations.
AUTHORITY TO RELEASE INFORMATION
To: Any Consumer Reporting Agency, including but not limited to any governmental agency, financial institution, any person having knowledge of my conduct or activities, or as otherwise defined by law:
I hereby authorize Northeast Michigan Community Mental Health Authority through its agents, to conduct an investigation of me, including, but not limited to my criminal history, if any, and driving record for the purposes of my employment including, but not limited to my application for employment, continued employment, retention, promotion, or other action as governed by the Fair Credit Reporting Act Public Law 91-508 or otherwise. I understand this investigation may include information about my character, general reputation, personal characteristics, and mode of living, and that the information may be gathered from various sources, including, but not limited to former employers, state and federal agencies, educational institutions and personal interviews. I further understand the information contained in my credit report may be used as a factor in any employment decision. I understand that I have the right to request, in writing, additional disclosures under the provisions of the Fair Credit Reporting Act. I authorize all persons who may have information relevant to this investigation to disclose it to the NEMCMHA or its agents, and I release all persons from liability because of such disclosure. I voluntarily waive any federal or state statutory requirements for advance notice of the disclosure, including my disciplinary history. I further authorize that a photocopy of this authorization may be considered as valid as an original.