BARBARA KETTLE GUNDLACH SHELTER
Application for Employment(Please Print)
Position(s) Applied forDate of Application

Last Name
Address

First NameNumber

StreetTelephone Number(s)Home:Middle Initial
City

State

Zip CodeSocial Security Number:
Cell:

Other:

If you are under 18 years of age, can you provide required
proof of your eligibility to work?

E-Mail: (optional)
Yes

No

Have you ever filed an application with us before?
YesNo
If yes, give date ___________________Have you ever been employed with us before?
YesNo
If yes, give date ____________________Are you currently employed?
Yes
NoAre you authorized to work in the United States?
Yes
NoOn what date would you be available for work?
__________________________________Are you available to work
Full time
Part time
Temporary
Can you travel if a job requires it?
Yes
NoAre you available to work weekends or evenings when required
Yes
Noby the position you have applied for?

License/ Certification
If the job you are applying for required driving a vehicle, do you posses
a valid Michigan driver’s license?
YesNo
If yes, indicate Driver’s License Number: _____________________________________________________
Is your license invalid or has it ever been revoked, suspended, or restricted?
Yes
No
If yes, please explain: ___________________________________________________________________________
Please list any other license, registration, certificate, etc. which is related to the job you are applying.
__________________________________________________________________________________________________________________________________________________________________________________________Have you ever had a license, registration, certificate, etc. related to this position you are applying for suspended,revoked, or placed on probation for any reason?
YesNo
If Yes, please
explain____________________________________________________________________________________________________________________________________________________________________________________Have you been convicted of a crime?
Yes
No
Conviction will not necessarily disqualify an applicant from employment.
If yes, please explain when, where and the nature of the offense.
__________________________________________________________________________________________________________________________________________________________________________
Are there any felony charges pending against you currently?

BARBARA KETTLE GUNDLACH SHELTER IS AN EQUAL OPPORTUNITY EMPLOYER

Education
Elementary School

High School

Undergraduate
College/ UniversityGraduate
Professional

School nameand location_____________________________________________________________________________________________
Years Completed
4 5 6 7 8
9 10 11 12
1 2 3 41 2 3 4_____________________________________________________________________________________________
Diploma/ Degree_____________________________________________________________________________________________
Describe Course of Study

Describe any specialized training or skills you have:

Describe any professional honors you have received:

Indicate any foreign languages you can speak, read and/or write _________________________________

Employment History
Please give an accurate, complete full-time and part-time employment record. Start with present or mostrecent employer, and go back a minimum of ten (10) years. Do not omit any employment during that time. Add
additional sheets if necessary. Answer each question completely and accurately. “See Resume” is not acceptable.

Name and Address of Employer
Job Title/ Position Held

Dates of Employment
From__ / __ / __ to __ / __ /__Job Responsibilities_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Supervisor’s Name and Title ____________________________________________________________________
Work Telephone ( ) ________________
Reason for Leaving: VoluntaryInvoluntary
Please explain:__________________________________________________________________________________________________________________________________________________________________________________________
May we contact your current employer prior to a job offer?

Yes

NoBARBARA KETTLE GUNDLACH SHELTER IS AN EQUAL OPPORTUNITY EMPLOYER

Name and Address of Employer
Job Title/ Position Held

Dates of Employment
From __ /__ / __ to __ /__ /__Job Responsibilities_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Supervisor’s Name and Title ______________________________________________________________________
Work Telephone () ________________
Reason for Leaving: Voluntary
Involuntary
Please explain:__________________________________________________________________________________________________________________________________________________________________________________________
May we contact your current employer prior to a job offer?

YesNo

Name and Address of Employer
Job Title/ Position Held

Dates of Employment
From __ / __ / __ to __ / __ /__Job Responsibilities_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Supervisor’s Name and Title ______________________________________________________________________
Work Telephone ( ) ________________
Reason for Leaving: Voluntary
Involuntary
Please explain:__________________________________________________________________________________________________________________________________________________________________________________________
May we contact your current employer prior to a job offer?

YesNoReferences, Title
Give the name, address, and telephone number of three professional references who are not related to you.
1.___________________________________________________________________________________

2.___________________________________________________________________________________

3.___________________________________________________________________________________BARBARA KETTLE GUNDLACH SHELTER IS AN EQUAL OPPORTUNITY EMPLOYER

Certification
I understand that all information in this application may be checked and I hereby authorize anyschools, which I have attended, current and previous employers and organizations named in thisapplication to provide the Barbara Kettle Gundlach Shelter Home with any information that may
be requested to make an employment decision. I further authorize the Barbara Kettle Gundlach
Shelter Home to conduct any other investigations of the information contained herein. I hereby
specifically waive written notice from all former employers regarding their disclosure to theBarbara Kettle Gundlach Shelter Home of any information, including disciplinary action.
I specifically authorize any requested law enforcement agencies to release to the Barbara Kettle
Gundlach Shelter Home any records of prior criminal convictions it may have or may obtainfrom other sources.
I understand that any omission or misrepresentation of information on this application may besufficient cause for rejection of this application or, if employment has commenced, grounds for
immediate dismissal.
I have read and understood the above statement; I hereby certify that all information contained inthis application is true, complete, and accurate.
Applicant Signature: _________________________

Date: ______________________For Office Use, Only
Job Title___________________________
Arrange Interview
YesNoInterview ___________________________

Date___________________________

Remarks__________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Employed

YesNo

Date of Employment _________________________

By _________________________________

Date: __________________________Notes______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
mbn 03/2023

BARBARA KETTLE GUNDLACH SHELTER IS AN EQUAL OPPORTUNITY EMPLOYER