Application Form

Please fill and submit form to apply.

Name*
First Last
Email*
Current Address*
Street Address Address Line 2 City State ZIP Code
How long have you lived at this address?*
Primary Phone*
Secondary Phone
Age*
Position Applying for*
Pay Rate Desired*
Please select the days you are available to work*
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
How many hours can you work weekly?*
Specific hours that you can not work
Please let us know if there are specific hours that you can not work and on what days.
Date that you are available to begin working
MM slash DD slash YYYY
Education: High School
Name of High School
City/Location*
Did you graduate?*
- Yes
- No
- Currently Attending
Education: College
Name of College
City/Location
Did you graduate?
- Yes
- No
- Currently Attending
Education: Business or Trade School
Name of Business or Trade School
City/Location
Did you graduate?
- Yes
- No
- Currently Attending
Education: Professional Schooling
Name of Professional School
City/Locaton
Did you graduate?
- Yes
- No
- Currently Attending
Criminal History
Have you ever been convicted of a Misdemeanor?*
- Yes
- No
Please Explain*
Have you ever been convicted of a Felony?*
- Yes
- No
Please Explain*
Prior to consideration for employment, do you agree to a DOT drug screen and medical physical?*
- Yes
- No
Prior to consideration for employment, do you agree to allow the SJCTA to run a criminal background check?*
- Yes
- No
Other names used
Please indicate any previous names including maiden name, and any other names wihch you have used or been known by.
Have you ever resided in a state other than Michigan ?*
- Yes
- No
Previous Out of State Address #1*
Street Address Address Line 2 City State ZIP Code
Previous Out of State Address #2
Street Address Address Line 2 City State ZIP Code
Previous Out of State Address #3
Street Address Address Line 2 City State ZIP Code
Consent to Criminal Background Check
I give permission to SJCTA to conduct a criminal background check to investigate my criminal history and driving record. I understand that the scope of this investigation will be limited to a criminal history background report and driving record report. I understand that the results from my criminal background check may result in my ineligibility to contract with a potential employer because of Medicaid regulations. Representative(s) of SJCTA administration will make this determination. In addition, I understand that any falsification or willful omission of fact made in connection with the criminal background check may be sufficient grounds for rejection of my eligibility to contract with SJCTA. This consent shall be in effect for one year from the date of signature.
*
- Yes, I consent to a criminal background check
Type full name as signature
This will act as your digital signature
Driving Information
Do you have a valid driver's license?*
- Yes
- No
Driver's License Number*
Driver's License State*
Driver's License Expiration Date*
MM slash DD slash YYYY
Please select the endorsement(s) you currently have*
- Operator
- Commercial License (CDL)
- Chauffer
- Passenger
Do you have a valid State ID?*
- Yes
- No
State ID Number*
Select State Issuer*
State ID Expiration Date*
MM slash DD slash YYYY
Do you have reliable transportation to and from work?*
- Yes
- No
Have you had any motor vehicle accidents during the past three (3) years?*
- Yes
- No
How many?*
Have you had any moving violations during the past three (3) years?*
- Yes
- No
How many?*
Skills and Experience
Can you type?*
- Yes
- No
Words per minute
Can you use a computer?*
- Yes, PC
- Yes, Mac
- Yes, PC and Mac
- No
Can you use a word processor program?*
- Yes
- No
Which programs?*
Word, Pages, OpenOffice, etc.
Do you have dispatch experience?*
- Yes
- No
Number of years experience*
Do you have professional driving experience?*
- Yes
- No
Number of years experience*
Are you an active member in the armed forces?*
- Yes
- No
References
Reference #1 Name*
First Last
Reference #1 Company*
Reference #1 Position
Reference #1 Phone*
Reference #1 Address*
Street Address Address Line 2 City State ZIP Code
Reference #1 Email*
Enter Email Confirm Email
References
Reference #2 Name*
First Last
Reference #2 Company*
Reference #2 Position
Reference #2 Phone*
Reference #2 Address*
Street Address Address Line 2 City State ZIP Code
Reference #2 Email*
Employer #1
Employment Started*
MM
DD
YYYY
Employment Ended
Month
Day
Year
- Currently Employed
Employer Name*
Job Title*
Name of last supervisor*
Reason for leaving (be specific)*
Position Information*
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Employer #2
Employment Started*
MM
DD
YYYY
Employment Ended
Month
Day
Year
- Currently Employed
Employer Name*
Job Title*
Name of last supervisor*
Reason for leaving (be specific)*
Position Information*
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Additional Qualifications
An application form sometimes makes it difficult for an individual to adequately summarize a complete background. Use the space above to summarize any additional information necessary to describe your full qualifications for the specific position for which you are applying.
Phone
This field is for validation purposes and should be left unchanged.

Application Form

Please fill and submit form to apply.

Education: High School

Education: College

Education: Business or Trade School

Education: Professional Schooling

Criminal History

Consent to Criminal Background Check

Driving Information

Skills and Experience

References

References

Employer #1

Employer #2