Careers - Harbor Hall

Applicant Information

Name

Date

Address

City

State

ZIP Code

Phone

Are you legally authorized to work in the United States? Are you legally authorized to work in the United States? Yes No

Position Information

Position Applied For

Date Available

Desired Salary

Education

High School/GED

City/State

Graduated Graduated Yes No

Graduation/Attendance Dates

College/University

Degree Received Degree Received Yes No

Date

Field(s) of Study

Postgraduate Institution

Degree Received Degree Received Yes No

Dates Attended

Field(s) of Study

Professional Licenses/Certifications

Work Experience

Employer 1

Name

Phone

Job Title/Position

Dates Employed

Responsibilities

Reason for Leaving

May we contact this employer May we contact this employer Yes No

Employer 2

Name

Phone

Job Title/Position

Dates Employed

Responsibilities

Reason for Leaving

May we contact this employer May we contact this employer Yes No

Employer 3

Name

Phone

Job Title/Position

Dates Employed

Responsibilities

Reason for Leaving

May we contact this employer May we contact this employer Yes No

Military Service (if applicable)

Branch

From

Rank at Discharge

Type of Discharge

If other than honorable, please explain

Professional References

(Please list three professional references, preferably former supervisors or colleagues.)

Name

Phone

Relationship

Name

Phone

Relationship

Name

Phone

Relationship

Have you ever been convicted of a felony offense? Have you ever been convicted of a felony offense? Yes No

A conviction will not automatically disqualify you. Factors such as age and nature of the offense, time since conviction, and relevance to the job will be considered in accordance with Michigan’s Clean Slate Law.

If yes, please explain

This position is contingent upon successful completion of a pre-employment drug screen and background check. By submitting this application, you acknowledge that:

You may be required to undergo a drug screen as a condition of employment.
You will be asked to complete and sign a separate background check authorization form, which complies with the federal Fair Credit Reporting Act (FCRA).
Employment is contingent upon results that are satisfactory to Harbor Hall and consistent with applicable laws and policies.

Applicant Statement and Signature

I certify that the information provided in this application is true and complete to the best of my knowledge. I understand that any false or misleading information provided in this application or during the interview process may result in disqualification or, if hired, termination of employment.
I authorize Harbor Hall to verify the information provided and to contact references and previous employers (unless otherwise noted). I understand this application is not a contract or guarantee of employment.

Signature Save Clear

Date

ADA Accommodation Notice

Harbor Hall complies fully with the Americans with Disabilities Act (ADA).
If you require an accommodation to complete this application or participate in the interview process, please contact Human Resources at [insert contact].

Applicant Information

Position Information

Education

Work Experience

Employer 1

Employer 2

Employer 3

Military Service (if applicable)

Professional References

A conviction will not automatically disqualify you. Factors such as age and nature of the offense, time since conviction, and relevance to the job will be considered in accordance with Michigan’s Clean Slate Law.

Applicant Statement and Signature

ADA Accommodation Notice

Petoskey Residential

Petoskey Outpatient

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