Position I am applying for * How did you hear about us? (Optional) Your Contact Phone Number * Social Security Number * Salary Requirement If you are under 18 and we require a work permit, can you furnish one? If the answer to the previous question was no, please explain why Have you ever worked for this company? * If the answer to the previous question was yes, when did you work for the company previously? Are you a citizen of the United States? * If the answer to the previous question was no, are you legally allowed to work in the United States? Type of employment desired * Have you ever pleaded "guilty", "no contest", or been convicted of a crime? *
Answering "Yes" to these questions does not constitute an automatic rejection for employment. Date of the offense, seriousness, and nature of the violation, rehabilitation, and position applied for will be considered.
If the answer to the previous question was yes, give dates and details Driver's License Number and Issuing State (If applicable to position) Résumé Upload
Upload a pdf, doc, docx, or txt file of your Résumé here.
Or Type Résumé Information Below Previous Employment Information
Please provide a pdf, doc, docx, or txt file containing previous employment information including: Dates of employment start and end, position title, company/firm, the address of the company/firm, the company/firm's phone number, the name of your Supervisor, your prior Job Resposibilities, and your Reason for Leaving.
Or Type Previous Employment Information Below
By signing below, I certify that my answers are true and complete to the best of my knowledge. I authorize you to make such investigations and inquiries of my personal, employment, educational, financial, and other related matters as may be necessary for an employment decision. I hereby release employers, school, and individuals from all liability when responding to inquiries in connection with my application.
In the event I am employed, I understand that false or misleading information given in my application or interview(s) may result in discharge,
Signature (Name) and Today's Date * --------------------------------------------------------------------------------------------- Reference Check Consent
I voluntarily consent to allow Professional Counseling Center or any of its officers, employees or agents to check my
personal and work related references by contacting any person they deem to be appropriate.
I understand the questions may be about my educational background, salary history, work behavior, performance ratings and/or any relevant experience. I also give Professional Counseling Center, P.C, permission to contact not only the references I have provided, but anyone else familiar with my job performance at any of the companies listed in my work history or personal acquaintances of mine you may know.
The provided listed references are hereby released from all liability for providing such information by signing below.
Signature (Name) and Today's Date * Reference Sheet Upload
Please upload a pdf, doc, docx, or txt file containing your work and/or personal references. Please include the reference's name, whether they are a work or personal reference, their company, address, and phone number.
Or Type Reference Information Below --------------------------------------------------------------------------------------------- Authorization and Consent for Pre-Employment Screening Form
In connection with my application for employment at
Professional Counseling Center, I hereby authorize the Employer and any agent it authorizes to perform a pre-employment background screening check (including future screenings for retention, promotion or re-assignment if applicable unless revoked in writing). I understand and agree to the following:
I understand that the employer may obtain information about me having a bearing on job performance, and may include information from public and private sources, public records, courts, schools, former employers and references concerning my driving record, court records, worker's compensation record, education, credentials, identity and previous employment.
I understand that personal information and fingerprints submitted by live scan are used to search against criminal identification records from both the Michigan State Police (MSP) and Federal Bureau of Investigation (FBI), National and local Sex Offender registries and Central Registry Check (DHS). I hereby authorize the release of any records to the person or agency listed above.
I authorize and release people, companies, references, current and former employers, schools, municipal, county, state and federal agencies and courts, to provide all information that is requested to the employer or its authorized agents. I further release and hold harmless all of the above, including the employer, to the full extent permitted by law, from any liability or claims arising from retrieving and reporting of information concerning me.
I agree a copy or fax of this document shall be valid as the original.
Have you ever been convicted of a crime? (Please exclude convictions for minor marijuana related offenses, convictions that have been sealed or legally eradicated and misdemeanor convictions for which probation was completed and the case was dismissed.) * Are you currently out on bail or released on your own recognizance pending trial? * If the answer to either one of the previous two questions is YES, please explain here. (An affirmative answer to any of the above will not necessarily disqualify you from employment).
By signing my name in the box below, I verify and affirm that all the information on this form and all information on my resume and application as well as all information given during any interview is true and correct. Any false information or material omission is grounds to terminate the hiring process, or to terminate employment at any time if it has started.
Signature (Name) and Today's Date *