Touchstone Services Inc.
"Our goal is simple...To help you reach yours"
Date: ______________
TOUCHSTONE SERVICES, INC.
JOB APPLICATION
Section I: Equal Employment Opportunity Employer
Touchstone Services, Inc. is an equal opportunity employer. It is the policy of this organization not to discriminate on the basis of race, sex, religion, national origin, marital status, age, weight, height, color, disability or veteran status in the hiring, promotion, compensation or discipline of employees.
If you are a person with a disability, you may request any needed reasonable accommodation to participate in the application process or interview process. Michigan law requires that a person with a disability or handicap requiring accommodation for employment must notify the employer in writing within 182 days after the need is known.
Section II: Applicant’s Personal Information
Name: ___________________________________________________________________
(please print) First Middle Initial Last
Present address: __________________________________________________________
(please print) Number Street
__________________ __________________ _____________
City MI Zip Code
Phone: (_____)_________________ Alternate/Cell: (___)______________________
Social Security Number: ___xxx-xx-______________ (last four digits only please)
Are you 18 years of age or older? ( ) Yes ( ) No
Can you perform the duties of the job for which you are applying with or without accommodation? ( ) Yes ( ) No
If no, please explain: _______________________________________________________
Do you have any relatives or a spouse employed by this organization? ( ) Yes ( ) No
If yes, please provide names: ________________________________________________
Name and address of a person to be notified in case of an emergency:
________________________________________________________________________
First Name Last Name
(____)_________________________ (____)_____________________________
Phone Alternate Phone
Have you ever been convicted of a crime? ( ) Yes ( ) No
(Answering “yes” to this inquiry will not automatically disqualify you.)
Are there any pending felony charges against you? ( ) Yes ( )No
(Answering “yes” to this inquiry will not automatically disqualify you.)
Have you ever worked for this organization in the past? ( ) Yes ( ) No
If so, did you work under a different name? ( ) Yes ( ) No
If yes, is any additional information relative to a different name necessary to check your work record? ( ) Yes ( ) No
If yes, please explain: _____________________________________________________
If the position for which you applied requires you to drive while on duty, do you have a valid driver’s license? ( ) Yes ( ) No
Section III: Availability and Interests in Work
For which position have you applied: ______________________________________
Have you been given a job description for this position? ( ) Yes ( ) No
Are you interested in full-time or part-time work? ( ) Full-time ( ) Part-time
Working some evenings, weekends and holidays, as well as some occasional overtime is expected for employment. Are you able to meet this requirement? ( ) Yes ( ) No
On what date are you available to start work? ____________________________
Section IV: Education
High School _______________________________ ___________________________
Name Street City State
Did you graduate? ( ) Yes ( ) No
College __________________________________ _____________________________
Name Street City State
Did you graduate? ( ) Yes ( ) No
If yes, what degree(s) did you obtain? _______________________________________
_________________________________________________________________________
Business or ______________________________________ ___________________
Trade School Name Street City State
Did you graduate? ( ) Yes ( ) No
If yes, what degree(s) or certificate(s) did you obtain? ____________________________
_________________________________________________________________________
Professional ______________________________________ ____________________
School Name Street City State
Did you graduate? ( ) Yes ( ) No
If yes, what degree(s) or certificate(s) did you obtain? ____________________________
_________________________________________________________________________
Section V: Employment History
(Please start with present or most recent employer)
Company Name: _____________________________ Telephone: ________________
Address: ____________________________________ Employment Dates (month/year)
Position Title: ________________________________ From: ___________ To: ______
Name of Supervisor: ___________________________ Reason for Leaving: ______________
Company Name: _____________________________ Telephone: ________________
Address: ____________________________________ Employment Dates (month/year)
Position Title: ________________________________ From: ___________ To: ______
Name of Supervisor: ___________________________ Reason for Leaving: ______________
Company Name: _____________________________ Telephone: ________________
Address: ____________________________________ Employment Dates (month/year)
Position Title: ________________________________ From: ___________ To: ______
Name of Supervisor: ___________________________ Reason for Leaving: ______________
Company Name: _____________________________ Telephone: ________________
Address: ____________________________________ Employment Dates (month/year)
Position Title: ________________________________ From: ___________ To: ______
Name of Supervisor: ___________________________ Reason for Leaving: ______________
May we contact your current supervisor or manager? ( ) Yes ( ) No
If no, why? ___________________________________________________________________
If yes, who should we call? ______________________________________________________
Name Title Phone
Have any of your previous employers served persons funded through a community mental health (CMH) entity? ( ) Yes ( ) No
If yes, which CMH entities were involved? ___________________________________________
May we contact the employers and CMH entities that you listed above to determine whether you have ever had a recipient rights violation substantiated against you? ( ) Yes ( ) No
Give the names of three (3) references from persons not related to you, whom you have known at least one (1) year:
Company Name: _____________________________ Telephone: ________________
Address: ____________________________________ Employment Dates (month/year)
Position Title: ________________________________ From: ___________ To: ______
Name of Supervisor: ___________________________ Reason for Leaving: ______________
Company Name: _____________________________ Telephone: ________________
Address: ____________________________________ Employment Dates (month/year)
Position Title: ________________________________ From: ___________ To: ______
Name of Supervisor: ___________________________ Reason for Leaving: ______________
Company Name: _____________________________ Telephone: ________________
Address: ____________________________________ Employment Dates (month/year)
Position Title: ________________________________ From: ___________ To: ______
Name of Supervisor: ___________________________ Reason for Leaving: ______________
Do you have any licenses, registrations or certifications? ( ) Yes ( ) No
If yes, please provide detail and include license number: _______________________________
_____________________________________________________________________________
I hereby give you my permission to contact the above employers, references and educational, licensing, credentialing and certification institutions to verify the items I listed above. I hereby release Touchstone Services, Inc. and the above listed referenced organizations, reference persons and employers from all claims, liability and damages that may result from furnishing the information to you. I consent to releasing any information relating to my job performance which is documented in my personnel file. In the event that a prior employer or other organization is obligated to provide any written notice to me regarding the disclosure of information to Touchstone Services, Inc., I hereby waive that obligation and expect no written notice of disclosure of my personal information.
I also understand that because of the nature of my job, I hereby consent to the release of this application or portions of this application to representatives of the Department of Community Health, Department of Human Services, local community mental health entities or other governmental agencies or private agencies for all investigatory purposes and to verify information I have listed in this job application. I hereby release Touchstone Services, Inc., the Department of Community Health, the Department of Human Services, local community mental health entities and other governmental agencies or private agencies from all claims, liability and damages that may result from furnishing the information to you.
I further specifically waive written notice and agree to the divulging of any disciplinary reports, letters of reprimand or other disciplinary action by all prior employers, and hereby release any prior employers from all claims, liability and damages that may result from furnishing the information to you.
___________________________________________________ ____________________
Applicant Signature Date
I certify that all of the information provided on this application is true, complete and correct.
I further understand and agree that any falsification, misrepresentation or omission of fact on this application or in any interviews or pre-employment process are grounds for disqualification for consideration for employment or termination of employment if the discovery is made after employment begins.
____________________________________________________ _________________
Applicant Signature Date
In consideration of my employment, I agree to conform to the policies, rules and regulations of Touchstone Services, Inc. I understand and agree that my employment and compensation are for no definite period and, may, regardless of the time and manner of my wages or salary, be terminated at-will with or without cause and with or without notice of any time, at sole discretion of Touchstone Services, Inc. or myself.
_____________________________________________________ ________________
Applicant Signature Date
_____________________________________________________ _______________
Employer Signature Date
This application will be kept current for 12 months. You need to complete another application to be reconsidered after this date.
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