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Download PDF Application Applicant InformationName(Required) First Last Preferred Name Address(Required) Street Address Address Line 2 City State 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 ZIP Code Email(Required) Phone(Required)Position Applied For(Required) Date Available(Required) Month Day Year Desired Wage / Salary(Required) Are You a Citizen of the United States?(Required) Yes No Have You Ever Worked for MVA?(Required) Yes No When? Have You Ever Been Convicted of a Felony?(Required) Yes No Please Explain Any Other Comments Regarding Items That May be on Background, License, Cedential, or Other Checks?EducationHighest Level of Education(Required) School Attended(Required) Did You Graduate?(Required) Yes No Degree Type(Required) EmploymentPlease enter at least the last 5 years of work history, starting with your most recent employer.Company(Required) Address(Required) Street Address Address Line 2 City State 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 ZIP Code Job Title(Required) Ending Wage(Required) Responsibilities / Duties(Required)Dates of Employment(Required)(e.g. January 2015 - May 2019) Supervisor or Contact Person(Required) Phone(Required)May We Contact Your Previous Supervisor for a Reference?(Required) Yes No ADD ANOTHER EMPLOYER?(Required) Yes No Company(Required) Address(Required) Street Address Address Line 2 City State 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 ZIP Code Job Title(Required) Ending Wage(Required) Responsibilities / Duties(Required)Dates of Employment(Required)(e.g. January 2015 - May 2019) Supervisor or Contact Person(Required) Phone(Required)May We Contact Your Previous Supervisor for a Reference?(Required) Yes No Military ServiceHave You Served?(Required) Yes No Branch Rank at Discharge Dates of Service(e.g. January 2015 - May 2019) Type of DischargeIf you choose to disclose. ReferencesPlease list 2 professional references and 1 personal reference.First Professional Reference(Required) First Last Phone(Required)Relationship(Required) Additional CommentsSecond Professional Reference(Required) First Last Phone(Required)Relationship(Required) Additional CommentsPersonal Reference(Required) First Last Phone(Required)Relationship(Required) Additional CommentsAttestationsI attest to all of the following:I am not currently using illegal drugs/ illicit substances.(Required) Agree I do not have a history of loss or limitation of treatment privileges or other disciplinary action; including Medicare / Medicaid sanctions.(Required) Agree I agree to completion of a criminal background check and will review any findings with MVA hiring staff, providing explanation as necessary, to confirm I am not disqualified as an employee.(Required) Agree I do not have felony conviction history that makes me ineligible for employment.(Required) Agree I certify my answers are true and complete to the best of my knowledge.(Required) Agree Attestations for Clinical StaffIs This Application for a Clinical Staff Position?(Required) Yes No I do not have a history of losing my professional license.(Required) Agree My professional license with the state of Michigan is current.(Required) Agree I have current certification credentials with MCBAP or have a development plan.(Required) Agree I have graduated from an accredited school.(Required) Agree I do not have professional liability claims or judgments against me in the past 5 years OR have provided explanation to MVA.(Required) Agree I have professional liability insurance either personal or provided by MVA.(Required) Agree Upload DocumentsYou may upload the following with your application: resume, copy of state issued ID, secondary form of identification, completed background check forms, and proof of professional credentials/ licensure. Supporting documents can be downloaded here.File Drop files here or Select files Accepted file types: pdf, jpg, jpeg, png, Max. file size: 2 MB, Max. files: 10. Disclaimer and SignatureIf this application leads to employment, I understand false or misleading information in my application or interview may result in my dismissal. Please type your full name below to sign this application digitally.Full Name(Required) CAPTCHA
