Employment Application "*" indicates required fields In order to be considered for employment, please fill out the following form completely. Personal InformationPosition Desired:*Select a PositionAlternate Position Desired:Application Date*Name* First Middle Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone*Date Available MM slash DD slash YYYY List any other name(s) by which you have been known by previous employer(s) or educational institution(s): Your Privacy is Protected This information is used to determine if our equal employment opportunity efforts are reaching all segments of the population, consistent with Federal equal employment opportunity laws. Responses to these questions are voluntary. Your responses will not be shown to the panel rating the applications, to the official selecting an applicant for a position, or to anyone else who can affect your application. This form will not be placed in your Personnel file nor will it be provided to your supervisors in your employing office should you be hired. The aggregate information collected through this form will be kept private to the extent permitted by law. See the Privacy Act Statement below for more information. Completion of this form is voluntary. No individual personnel selections are made based on this information. There will be no impact on your application if you choose not to answer any of these questions. Thank you for helping us to provide better service.SexChoose OneMaleFemaleEthnicityChoose OneHispanic or Latino - a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.Not Hispanic or LatinoDisability/Serious Health Condition The next questions address disability and serious health conditions. Your responses will ensure that our outreach and recruitment policies are reaching a wide range of individuals with physical or mental conditions. Consider your answers without the use of medication and aids (except eyeglasses) or the help of another person.Do you have any of the following? Check all boxes that apply to you: Deaf or serious difficulty hearing Blind or serious difficulty seeing even when wearing glasses Missing an arm, leg, hand, or foot Paralysis: Partial or complete paralysis (any cause) Significant Disfigurement: for example, severe disfigurements caused by burns, wounds, accidents, or congenital disorders Significant Mobility Impairment: for example, uses a wheelchair, scooter, walker or uses a leg brace to walk Significant Psychiatric Disorder: for example, bipolar disorder, schizophrenia, PTSD, or major depression Intellectual Disability (formerly described as mental retardation) Developmental Disability: for example, cerebral palsy or autism spectrum disorder Traumatic Brain Injury Dwarfism Epilepsy or other seizure disorder Other disability or serious health condition: for example, diabetes, cancer, cardiovascular disease, anxiety disorder, or HIV infection; a learning disability, a speech impairment, or a hearing impairment If you did not select one of the options above, please indicate whether. None of the conditions listed above apply to me. I do not wish to answer questions regarding disability/health conditions. If you have indicated that you have one of the above conditions, you may be eligible to apply under Schedule A Hiring Authority. For more information, please see http://www.opm.gov/policy-data-oversight/disability-employment/hiring/#url=Schedule-A-Hiring-Authority .Other Disability or Serious Health Condition (Optional) I do not wish to specify any condition. Alcoholism Cancer Cardiovascular or heart disease Crohn’s disease, irritable bowel syndrome, or other gastrointestinal impairment Depression, anxiety disorder, or other psychological disorder Diabetes or other metabolic disease Difficulty seeing even when wearing glasses Hearing impairment History of drug addiction (but not currently using illegal drugs) HIV Infection/AIDS or other immune disorder Kidney dysfunction: for example, requires dialysis Learning disabilities or ADHD Liver disease: for example, hepatitis or cirrhosis Lupus, fibromyalgia, rheumatoid arthritis, or other autoimmune disorder Morbid obesity Nervous system disorder: for example, migraine headaches, Parkinson’s disease, or multiple sclerosis Non-paralytic orthopedic impairments: for example, chronic pain, stiffness, weakness in bones or joints, or some loss of ability to use parts of the body Orthopedic impairments or osteo-arthritis Pulmonary or respiratory impairment: for example, asthma, chronic bronchitis, or TB Sickle cell anemia, hemophilia, or other blood disease Speech impairment Spinal abnormalities: for example, spina bifida or scoliosis Thyroid dysfunction or other endocrine disorder Other You indicated that you have a disability or a serious health condition. If you are willing, please select any of the conditions listed below that apply to you. As explained above, your responses will not be shown to the panel rating the applications, to the selecting official, or to anyone else who can affect your application. All responses will remain private to the extent permitted by law. See the Privacy Act Statement below for more information. Please check all that apply.Please identify the disability/health condition, if willing PRIVACY ACT AND PAPERWORK REDUCTION ACT STATEMENTS Privacy Act Statement: This Privacy Act Statement is provided pursuant to 5 U.S.C. 552a (commonly known as the Privacy Act of 1974). The authority for this form is 5 U.S.C. 7201, which provides that the Office of Personnel Management shall implement a minority recruitment program, by the Uniform Guidelines on Employee Selection Procedures, 29 C.F.R. Part 1607.4, which requires collection of demographic data to determine if a selection procedure has an unlawful disparate impact, and by Section 501 of the Rehabilitation Act of 1973, which requires federal agencies to prepare affirmative action plans for the hiring and advancement of people with disabilities. Data relating to an individual applicant are not provided to selecting officials. This form will be seen by Human Resource personnel in the Office of Personnel Management (who are not involved in considering an applicant for a particular job) and by Equal Employment Opportunity Commission officials who will receive aggregate, non-identifiable data from the Office of Personnel Management derived from this form. Purpose and Routine Uses: The aggregate, non-identifiable information summarizing all applicants for a position will be used by the Office of Personnel Management and by the Equal Employment Opportunity Commission to determine if the executive branch of the Federal Government is effectively recruiting and selecting individuals from all segments of the population. Effects of Nondisclosure: Providing this information is voluntary. No individual personnel selections are 4 made based on this information. There will be no impact on your application if you choose not to answer any of these questions. Paperwork Reduction Act Statement: The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et. seq,) requires us to inform you that this information is being collected for planning and assessing affirmative employment program initiatives. Response to this request is voluntary. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB Control Number. The estimated burden of completing this form is five (5) minutes per response, including the time for reviewing instructions. Direct comments regarding the burden estimate or any other aspect of this form to Mistequay Group, 1156 N. Niagara St. Saginaw, MI 48602 and to the Office of Management Budget, Office of Information and Regulatory Affairs, Washington, DC 20503. Past Employment Start with current or most recent position. Please include a minimum of the last 7 years.First EmployerName*Your PositionAddress* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employed From MM slash DD slash YYYY Employed To MM slash DD slash YYYY Starting Hourly WageFinal Hourly WageDescription of Work PerformedReason for leavingMay we contact this employer?* Yes No Second Employer Add a Second Employer? NameYour PositionAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employed From MM slash DD slash YYYY Employed To MM slash DD slash YYYY Starting Hourly WageFinal Hourly WageDescription of Work PerformedReason for leavingMay we contact this employer?* Yes No Third Employer Add a Third Employer? NameYour PositionAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employed From MM slash DD slash YYYY Employed To MM slash DD slash YYYY Starting Hourly WageFinal Hourly WageDescription of Work PerformedReason for leavingMay we contact this employer?* Yes No Fourth Employer Add a Fourth Employer? NameYour PositionAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employed From MM slash DD slash YYYY Employed To MM slash DD slash YYYY Starting Hourly WageFinal Hourly WageDescription of Work PerformedReason for leavingMay we contact this employer?* Yes No Education Start with current or most recent schoolName & Address of SchoolCourse of StudyYears AttendedDid you graduate?* Yes No Degree/DiplomaSecond School Add a Second School? Name & Address of SchoolCourse of StudyYears AttendedDid you graduate?* Yes No Degree/DiplomaThird School Add a Third School? Name & Address of SchoolCourse of StudyYears AttendedDid you graduate?* Yes No Degree/DiplomaFourth School Add a Fourth School? Name & Address of SchoolCourse of StudyYears AttendedDid you graduate?* Yes No Degree/DiplomaAcademic honors or special recognition Employment References (must be professional work related references, 3 are required) Give Name(s) of person(s) we may contact to verify your qualifications for the positionFirst ReferenceNameOccupationOrganizationRelationshipTelephone NumberAddressSecond ReferenceNameOccupationOrganizationRelationshipTelephone NumberAddressThird ReferenceNameOccupationOrganizationRelationshipTelephone NumberAddress General InformationPlease select the days you are willing to work Sunday Monday Tuesday Wednesday Thursday Friday Saturday Please select the times you are willing to work Full-time Part-time Weekend Package Temp Summer Hours per week?What shifts can you work? Days Evenings Nights Holidays What is your expected starting salary?List the name and relationship of any relative currently employed by Mistequay GroupCheck the appropriate box next to each statement below. Checking "Yes" may not automatically disqualify you from employment. Non-disclosure of information may be considered falsification of records.Have you ever been convicted of a crime other than a simple misdemeanor offense relating to motor vehicles and laws of the road under chapter 321 or equivalent provisions in this state or any other state? This includes but is not limited to "guilty pleas, deferred judgements", etc. If you have questions regarding this, please ask Human Resources as we will have to rescind the job offer if a "crime" shows up on the background check and you have checked "No" to this question. Failure to disclosure prior convictions may disqualify your application.* Yes No Have you ever had a professional license subject to suspension or revocation?* Yes No Have you ever voluntarily relinquished your professional license?* Yes No Can you, if hired, submit verification of your legal right to work in the U.S.? Yes No If hired, you will be required to submit documents sufficient to establish employment authorization and identity in compliance with the immigration Reform & Control Act of 1986?Have you ever been employed by this organization before?* Yes No If yes, when?Are you 18 or over? Yes No Have you ever been excluded or precluded from participation in Medicare, Medicaid, or any other Federal or State healthcare program or otherwise been debarred or prohibited from contracting with the Federal or State government?* Yes No Are you an honorably discharged veteran?* Yes No Do you have a record of founded child or dependent adult abuse, or have you ever been convicted of a crime in this or any other state?* Yes No If yes, please explainIf required, information will be verified through a criminal record investigation. A conviction will not automatically disqualify an applicant for a particular job. The type and seriousness of the crime, the frequency of violations, the applicant's age at the time of conviction, the date of conviction, and the applicant's entire work and educational history will be considered.How did you hear about the position?* Mistequay Website Billboard Mistequay Vehicle Radio Ad TV Newspaper Indeed JuJu Simply Hired Glassdoor Monster Facebook Linkedin Recruiter Friend Current Employee Other Please list NewspaperPlease list EmployeePlease list other option Applicant Authorization *Signed:Date* MM slash DD slash YYYY Attach ResumeAccepted file types: pdf, doc, docx, txt, rtf, Max. file size: 128 MB.Captcha
