OLHSA Employment Application

A career at OLHSA is an opportunity to grow both personally and professionally, while serving our communities and each other. We strive to build a positive, supportive, and inclusive culture with caring leaders focused on helping people and changing lives.

OLHSA is a drug free workplace and an equal opportunity employer. We are committed to the full inclusion of all qualified individuals. OLHSA will ensure that persons with disabilities are provided reasonable accommodations.

Your Information
Employment History
Additional Information
Education
References
Additional Disclosures and Agreements
Legal Disclosures and Agreement
Criminal Background Check Policy and Disclosure

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Contact Information
Position Applied For
Available Date
Month / Day / Year
Employment Type
It is the policy of the Oakland Livingston Human Service Agency ("the Company") to ensure equal treatment and opportunity in all aspects of employment without regard to race, color, religion, sex, marital status, age, national origin, ancestry, status as a qualified individual with a disability, veteran status or other legally protected category, unless one of the above factors is a bona fide qualification for the job. This policy applies to all employment practices, including recruiting, hiring, training, compensation, benefits, advancement, pregnancy, and all other conditions of employment.
First Name
Middle Initial(s)
Last Name
Email
Home Phone
Phone Number
Mobile Phone
Phone Number

Present Address

Street Address
Street Address 2
City	State
Postal Code	Country

Have you been convicted of a felony within the last seven (7) years (excluding sealed or expunged convictions)?
Yes
No
Please provide date, place, offense, and outcome
Please note that a conviction will not necessarily exclude you from employment.
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?
Yes
No
Have you worked for OLHSA previously?
Yes
No
Please provide the Location and dates of employment
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Employment History
Have you been employed in any capacity in the past five (5) years?
Yes
No
Please list your employment for the past five (5) years, beginning with the most recent.
Employment Dates
Format: mm/yyyy - mm/yyyy
Ending Salary
Reason for Leaving
Company Name
Company Phone
Phone Number
Position

Company Address

Street Address
Street Address 2
City	State
Postal Code	Country

Supervisor Name
Supervisor Phone
Phone Number
Employment Dates
Format: mm/yyyy - mm/yyyy
Ending Salary
Reason for Leaving
Company Name
Company Phone
Phone Number
Position

Company Address

Street Address
Street Address 2
City	State
Postal Code	Country

Supervisor Name
Supervisor Phone
Phone Number
Employment Dates
Format: mm/yyyy - mm/yyyy
Ending Salary
Reason for Leaving
Company Name
Company Phone
Phone Number
Position

Company Address

Street Address
Street Address 2
City	State
Postal Code	Country

Supervisor Name
Supervisor Phone
Phone Number
Employment Dates
Format: mm/yyyy - mm/yyyy
Ending Salary
Reason for Leaving
Company Name
Company Phone
Phone Number
Position

Company Address

Street Address
Street Address 2
City	Region
Postal Code	Country

Supervisor Name
Supervisor Phone
Phone Number
Please explain any lapses in prior employment
If no lapses exist, please use "N/A"
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Education
High School
Name
City
Years Completed
Did You Graduate?
Yes
No
Degrees Received
College
Name
City
Years Completed
Did You Graduate?
Yes
No
Degrees Received
Post-College
Name
City
Did You Graduate?
Yes
No
Degrees Received
Other Education (Trade School)
Name
City
Years Completed
Did You Graduate?
Yes
No
Degrees Received
Please list special skills and training you would like considered for employment with OLHSA (i.e. typing, speed, computer skills, certifications, etc.
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References
Please list three (3) Professional or Personal references. Do not list former employers or relatives.
Name
Phone
Phone Number
Email
How do you know this person?
Name
Phone
Phone Number
Email
How do you know this person?
Name
Phone
Phone Number
Email
How do you know this person?
DO NOT SIGN AS REQUESTED BELOW UNTIL YOU HAVE READ THIS ENTIRE DOCUMENT, UNDERSTAND ITS TERMS AND CONDITIONS, AND AGREE TO THE TERMS AND CONDITIONS SET FORTH HEREIN. YOUR SIGNATURE BELOW INDICATES YOUR AGREEMENT TO THE TERMS AND CONDITIONS SET FORTH IN THIS APPLICATION. THE CONSIDERATION FOR YOUR ACCEPTANCE OF THE TERMS AND CONDITIONS SET FORTH HEREIN IS THE COMPANY'S WILLINGNESS TO REVIEW YOUR APPLICATION AND EMPLOYMENT IF YOU ARE SELECTED FOR EMPLOYMENT.

By typing my name below, I certify that all answers to questions in the application, and other reference documents cited above are true and complete to the best of my knowledge. I understand that misrepresentation, omission, or falsified statements on this Application or any other reference documents in any detail shall constitute sufficient cause for disqualification from further consideration for hire or for dismissal whenever discovered.
Your Legal First Name and Last Name
Date
Month / Day / Year

ADDITIONAL DISCLOSURES AND AGREEMENTS

I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States, and that federal immigration laws require me to complete an l-9 Form in this regard. I further understand that to be eligible for employment, I must complete the entire application process which may include a medical examination.

I expressly authorize, without reservation, the Company, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive any and all rights and claims I may have regarding the Company, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me.

In order to process your application, or during the course of your employment, the following reports may be obtained: National Criminal Background Screening, Internet Criminal History Access Tool (ICHAT- Michigan Criminal History Record), a National/State Sex Offender Registry (SOR) check, Michigan Public Sex Offender Registry check, and a Central Registry Clearance.

I understand that the Company does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law.
I understand that this application remains current for only six (6) months. At the conclusion of that time, if I have not heard from the Company and still wish to be considered for employment, it will be necessary for me to reapply and complete a new application.

In consideration of my employment, I agree to conform to the company's rules and regulations, and I agree that my employment and compensation can be terminated, with or without cause, and with our without notice, at any time, at either my or the company's option. I also understand and agree that the terms and conditions of my employment may be changed, with or without cause, and with or without notice, at any time by the company. I understand that no company representative, other than its Chief Executive Officer, and then only when in writing and signed by the Chief Executive Officer, has any authority to enter into any agreement for employment for any specific period of time, or to make any agreement contrary to the foregoing.

I further agree that, if employed, I will conform my conduct to the Company's rules and regulations, and that I may not enter into any other employment or engage in any business which will conflict with my responsibilities as an employee of the Company.

By typing my name below, I certify that all answers to questions in the application, and other reference documents cited above are true and complete to the best of my knowledge. I understand that misrepresentation, omission, or falsified statements on this application or any other reference documents in any detail shall constitute sufficient cause for disqualification from further consideration for hire or for dismissal whenever discovered.
Your Legal First Name and Last Name
Date
Month / Day / Year

1. LEGAL DISCLOSURES AND AGREEMENT

To the extent permitted by state law, I understand and agree that I shall not commence any state law action or suit related to my employment with the company:1) more than six months after the termination of my employment, if the action or suit is related to the termination of my employment; or 2) more than six months after the event or occurrence on which my claim is based, if the action or suit is based on an event or occurrence other than the termination of my employment. While I understand that the statute of limitations for state law claims arising out of my employment with company may be longer than six (6) months, I agree to be bound by the six (6) month period of limitations set forth herein and I waive any statute of limitations to the contrary. Should a court determine in some future lawsuit that this provision allows an unreasonable short period of time to commence a lawsuit, the court shall enforce this provision as far as possible and shall declare the lawsuit barred unless it was brought within the minimum reasonable time within which the suit should have been commenced.

I understand and agree that I shall not commence any EEOC administrative action related to my employment with the company:1) more than six months after the termination of my employment, if the action or suit is related to the termination of my employment; or 2) more than six months after the event or occurrence on which my claim is based, if the action or suit is based on an event or occurrence other than the termination of my employment. While I understand that the time period for filing an EEOC charge may be longer than six (6) months, I agree to be bound by the six (6) month period of limitations set forth herein and I waive any statute of limitations or filing requirement to the contrary.

To the extent permitted by law, I understand and agree that any federal law claim or lawsuit relating to my employment with the company must be filed no more than 185 days after the date of filing a proper and timely charge with the eeoc, nlrb, or any other administrative agency. While I understand that the statute of limitations for claims arising out of an employment action may be longer than 185 days, I waive any statute of limitations to the contrary.

By typing my name below on this document, I certify that I have read this Legal Disclosures and Agreement set forth above, had an opportunity to discuss the Legal Disclosures and Agreement with counsel of my choice, and understand that without my agreement to the Legal Disclosures and Agreements, OLHSA would not consider my application for employment. I further understand and request that the limitations be strictly enforced and that I am signing the limitations on my own free will.
Your Legal First Name and Last Name
Date
Month / Day / Year

2. CRIMINAL BACKGROUND CHECK POLICY AND DISCLOSURE

As a condition of employment, each employee is subject to a criminal background check. In conducting criminal background checks, OLHSA will comply with federal laws that protect applicants and employees from discrimination. That includes discrimination based on race, color, national origin, sex, GBL T status, religion; disability; genetic information (including family medical history); and age (40 or older).

In addition, OLHSA, to the extent required, will comply with the Fair Credit Reporting Act (FCRA) with regard to conducting criminal background checks. The Federal Trade Commission (FTC) enforces the FCRA.

To the extent that the prospective employee is seeking a job working with children, the prospective employee is also subject to a search on Michigan's sex offender registry.

Although a disqualification is possible, in accordance with federal and state laws, a previous conviction does not automatically disqualify an applicant from consideration for employment with OLHSA, unless such employment involves working with children and the conviction or criminal conduct relates to children or a clean record is required given the job duties, funding source, or employment source.

In conducting criminal background checks and convictions, OLHSA complies with the EEOC guidelines regarding the use of criminal background checks and specifically follows the "Green Factors" set forth in Green v. Missouri Pacific Railroad. The "Green Factors" requires OLHSA to evaluate the criminal background check report under the following test which assesses whether and exclusion is job related for the position in question and consistent with business necessity:
- The nature and gravity of the offense or conduct;
- The time that has passed since the offense or conduct and/or completion of the sentence; and
- The nature of the job held or sought.
To the extent that the criminal background check reveals conduct that would exclude the person from the specific job applied for after applying the "Green Factors," and to the extent that the basis for denying the job was related to the criminal background check, OLHSA will send out an appropriate letter to the prospective employee explaining the basis for denial of the job. The prospective employee shall have ten days after the date of the correspondence explaining the basis for denial of the job to contact the OLHSA and schedule a meeting explaining how the criminal background conduct should not exclude him/her. Failure by the prospective employee to contact OLHSA within the ten (10) day period as provided above, shall constitute of waiver of such right to engage the OLHSA regarding the decision to deny employment.

If you have any questions regarding your rights, please feel free to contact the Human Resource Department at OLHSA or the EEOC at www.eeoc.gov.

By typing my name below on this Application, I certify that all answers to questions in the application, and other reference documents are true and complete to the best of my knowledge. I understand that misrepresentation, omission, or falsified statements on this application or any other reference documents in any detail shall constitute sufficient cause for disqualification from further consideration for hire or for dismissal whenever discovered.
Your Legal First Name and Last Name
Date
Month / Day / Year

OLHSA Employment Application

Contact Information

Employment History

Additional Information

Education

High School

College

Post-College

Other Education (Trade School)

References