TRICAP

Equal Opportunity Employer

The following information is requested in order to help us make the best possible placement within the company. All portions of this application pertaining to you must be completed. We appreciate the time you spend in filling out this application form. Tri-Cap, Inc., in accordance with State and Federal laws, does not discriminate on the basis of age, race, religion, color, sex, height, weight, national origin, veteran’s status, marital status, disability, genetic information, military status, or any other legally protected status. SPECIAL EMPLOYMENT NOTICE Michigan law prohibits discrimination in employment based on disability. Beginning June 25th, 1990, applicant or employee requiring accommodation for employment must notify the employer in writing within 182 days after the need is now. Accommodation request should be submitted to Human Resources.

Drug Testing Requirement

All applicants must pass a drug screen to gain employement. This includes the use of THC. All TRICAP staff are subject to random drug testing at any time during employement.

Applicant Information

Name *

First

Middle

Last

Present Address

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Email *

Position Applying For *

Are you over 18 years of age?

yes
no

Some jobs at TRICAP may require work on Saturdays, Sundays, and holidays. While reasonable accommodation can be made for you, are you willing to work such a schedule?

yes
no

If “no”, please briefly explain:

If hired, when would you be available to start?

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RECORD OF EDUCATION

High School Attended

Address Line 1

Address Line 2

City

State

Zip Code

Did you graduate?

yes
no

College or University Attended (if applicable)

Address Line 1

Address Line 2

City

State

Zip Code

Course of Study

Number of Years Completed

Did you graduate?

yes
no

Degree / Certification

Other Educational Institution Attended (if applicable)

Address Line 1

Address Line 2

City

State

Zip Code

Course of Study

Number of Years Completed

Did you graduate?

yes
no

Degree / Certification

Are you attending or have you completed any classes or specialized training that would qualify you for this position?

yes
no

If yes, please describe.

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EMPLOYMENT HISTORY

List below all present and past employment, beginning with your most recent.

Employer Name & Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates of Employment - mm/yyyy to mm/yyyy

Title and Work Responsibilities

Supervisor Name

Reason for Leaving

Employer Name & Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates of Employment - mm/yyyy to mm/yyyy

Title and Work Responsibilities

Supervisor Name

Reason for Leaving

Employer Name & Address

Address Line 1

Address Line 2

City

State

Zip Code

Dates of Employment - mm/yyyy to mm/yyyy

Title and Work Responsibilities

Supervisor Name

Reason for Leaving

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MILITARY SERVICE RECORD

Where you in the Armed Forces?

yes
no

If yes, which branch?

Please describe any job related military training.

What was your rank at discharge?

REFERENCES

List names and telephone numbers of three (3) personal/business references who are not related to you.

Reference #1 *

First

Last

Number of Years Known

Phone *

Email

Reference #2 *

First

Last

Number of Years Known

Phone *

Email

Reference #3 *

First

Last

Number of Years Known

Phone *

Email

COVER LETTER & RESUME

Cover Letter *

Resume *

Click or drag a file to this area to upload.

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ACKNOWLEDGEMENT & CERTIFICATION

Have you ever been convicted of a crime?

yes
no

If yes, when, where and what was the nature of the offense?

Are there any felony charges pending against you?

yes
no

If yes, when, where and what is the nature of the charge?

Are you legally eligible for employment in the country?

yes
no

I acknowledge that consideration for employment is contingent on the results of a reference and criminal background check (lien). Therefore, I authorize TRICAP to: (1) investigate the truthfulness of all statements made on this application; (2) contact my former employers and other listed references or any other persons who can verify information; (3) discuss results of any investigation with other managers of TRICAP involved in the hiring process. In addition, I give my consent for all contacted persons, including former employers, to provide information concerning this application, and I release each such person from liability for providing information to TRICAP. I certify that the information contained in this application is correct to the best of my knowledge, and understand that falsification of this application in any detail is grounds for disqualification from further consideration or for dismissal from employment in accordance with the TRICAP policy.

I agree

Name *

First

Last

Disclaimer

TRI-CAP shall not hire or promote anyone who may have contact with residents, and shall not enlist the services of any contractor who may have contact with residents, who- (1) Has engaged in sexual abuse in prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997); (2) Has been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse; or (3) Has been civilly or administratively adjudicated to have engaged in the activity described in number (2) of this section. (4) Has any incidents of sexual harassment. TRI-CAP will use this information in determining whether to hire or promote anyone, or to enlist the services of any contractor, who may have had contact with residents. Do any of the above examples apply to you? YES______ NO______ if yes, please explain _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________