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Free Michigan 0999D Template in PDF

The Michigan 0999D form is an employment application used by the Michigan Department of Transportation (MDOT). This form is essential for individuals seeking employment within the department, as it collects vital personal and professional information. Applicants are encouraged to submit their resumes along with this form, although the application itself is mandatory.

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Structure

The Michigan 0999D form serves as an essential employment application for individuals seeking positions within the Michigan Department of Transportation (MDOT). This form requires applicants to provide personal information, including their name, contact details, and employment history. It also includes sections for educational background, licensure, and veteran status, which can be crucial for specific job considerations. Applicants are prompted to disclose any previous employment with the State of Michigan, ensuring that all relevant experience is noted. Additionally, the form emphasizes the importance of accuracy, as any misrepresentation could jeopardize employment opportunities. Notably, the application also addresses accommodations for individuals with disabilities, reflecting MDOT's commitment to equal opportunity. By completing this form, candidates not only express their interest in a position but also authorize background checks and reference verifications as part of the hiring process. Overall, the Michigan 0999D form is a comprehensive tool that facilitates the application process while ensuring compliance with employment regulations.

Form Example

of Transportation	EMPLOYMENT APPLICATION	Page 1 of 3
Michigan Department		Page 1 of 3
0999D (01/07)	Equal Opportunity Employer
0999D (01/07)

A MDOT APPLICATION IS REQUIRED, resumes are encouraged, but are not a substitute for the application. Submit application to Ofﬁce of Human Resources, 934 Bridge Plaza, Sault Ste. Marie, Michigan 48783. Fax Number: (906) 635-0540.

POSITION FOR WHICH YOU ARE APPLYING

Posting Code: _______________________________________________ Bureau/Region/Ofﬁce/Division: __________________________________

Position Location: _____________________________________________ JOB TITLE: _______________________________________________

Are you or have you ever been a State of Michigan employee?

Yes

No If Yes, Employee ID # required: _________________

If you have a disability, as deﬁned by the Michigan Persons with Disabilities Civil Rights Act, and require assistance to complete this application, a reasonable accommodation may be provided.

PERSONAL INFORMATION

Name: __________________________________________________________________________________________________________________

Mailing Address: _________________________________________________________________________________________________________

City: _________________________________________________________________ State: _________________ Zip Code: __________________

Email Address: _______________________________________________	Drivers License Number: ______________________________________
Day Time Telephone Number: (_______) __________________________	Home Telephone Number: (_______) _____________________________

Previous name(s) if different than current name: _________________________________________________________________________________

Have you ever been dismissed from employment or resigned your employment in lieu of dismissal?

Yes

If Yes, when and please explain: _____________________________________________________________________________________________

NAME/LOCATION OF HIGH SCHOOL:

DIPLOMA:

Yes

No	Other (Specify) ______________

COLLEGE, UNIVERSITY, TRADE SCHOOL OR SPECIAL TRAINING: (TRANSCRIPTS ARE REQUIRED)

NAME OF SCHOOL

LOCATION

CREDIT HOURS EARNED

QTR SEM

COURSE OF STUDY

DEGREE OR CERTIFICATE RECEIVED

TRADE SCHOOL/SPECIAL TRAINING

YOUR NAME, IF DIFFERENT WHILE ATTENDING SCHOOL: _____________________________________________________________________

LICENSURE OR REGISTRATION EXAMPLES: CDL, PE, CPA, ETC.

LICENSURE OR REGISTRATION

NUMBER

DATE RECEIVED

EXPIRATION DATE

STATE LICENSING AGENCY

VETERAN:

Are you a veteran, surviving spouse or a spouse of a disabled veteran who has been discharged within the last ﬁve years?						Yes		No
If yes, are you registered with Civil Service for veterans’ preference?		Yes		No

CITIZENSHIP:

Are you a U.S. Citizen?	Yes	No
If No, are you eligible to work in the U.S. without sponsorship?				Yes	No
Do you possess a valid Western Hemisphere Travel Initiative Document: ______Passport					______ Passport Card ______NEXUS ______ Other
			If "Other", please specify: ______________________________________

MDOT 0999D (01/07)

Page 2 of 3

PERIODS OF EMPLOYMENT

Describe your work experience in detail, beginning with your current or most recent job. Include job related voluteer work, if applicable, and indicate number of employees supervised. Use a separate block to describe each position. If needed, attach additional sheets, using the same format as the application. Resumes may be attached to provide additional information.

1Name of Present or Last Employer: _______________________________________________________________________________________

Address: ___________________________________________________________________ Phone No.: (________)__________________________

Your Job Title: ________________________________________________				Supervisor’s Name: __________________________________________
FROM: _______/_______/_______ TO: _______/_______/_______				HOURS PER WEEK: _______ (________________________________)
MONTH DAY	YEAR	MONTH DAY	YEAR	YOUR NAME IF DIFFERENT DURING EMPLOYMENT

Duties and Responsibilities: _______________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

Reason for Leaving: ______________________________________________________________________________________________________________________

2Name of Present or Last Employer: _______________________________________________________________________________________

Address: ___________________________________________________________________ Phone No.: (_______)___________________________

Your Job Title: ________________________________________________				Supervisor’s Name: __________________________________________
FROM: _______/_______/_______ TO: _______/_______/_______				HOURS PER WEEK: _______ (________________________________)
MONTH DAY	YEAR	MONTH DAY	YEAR	YOUR NAME IF DIFFERENT DURING EMPLOYMENT

Duties and Responsibilities: _______________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

Reason for Leaving: ______________________________________________________________________________________________________________________

3Name of Present or Last Employer: _______________________________________________________________________________________

Address: ___________________________________________________________________ Phone No.: (________)__________________________

Your Job Title: ________________________________________________				Supervisor’s Name: __________________________________________
FROM: _______/_______/_______ TO: _______/_______/_______				HOURS PER WEEK: _______ (________________________________)
MONTH DAY	YEAR	MONTH DAY	YEAR	YOUR NAME IF DIFFERENT DURING EMPLOYMENT

Duties and Responsibilities: _______________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________

Reason for Leaving: ______________________________________________________________________________________________________________________

CERTIFICATION

I certify that all information contained in this application is true, and made in good faith. I agree and understand any falsiﬁcations, omissions, misstate- ments, or misrepresentations above will result in my forfeiting any rights of consideration for employment with the Michigan Department of Transportation or, if hired, could lead to my dismissal. Under the Michigan Persons with Disabilities Civil Rights Act, a person with a disability may allege a violation of the Act regarding the failure to accommodate only if the person with a disability notiﬁes the employer in writing of the need for accommodation within 182 days after the date the person with a disability knew or reasonably should have known an accommodation was needed. This does not preclude my rights under federal law which establishes a 300 day status of limitation.

By submission of this application, I am authorizing the Michigan Department of Transportation to conduct a criminal history and background check, contact past employers regarding references and to check my motor vehicle operator license record as part of the pre-employment process.

SIGNATURE: ___________________________________________________________________________ DATE: _________________________

MDOT 0999D (01/07)Page 3 of 3

_EEO SURVEY
_
Although the following information is not mandatory, it is requested to comply with Federal Highway Administration (FHWA) require-
_
ments. This information is for statistical purposes only. It will in no way affect your employment status or opportunities, nor will it be
_
used as part of the selection process (hiring managers will not receive this information).
___Posting Code: _______________________________________________			Bureau/Region/Ofﬁce/Division: __________________________________
__Position: ___________________________________________________			Location of Position___________________________________________
____	MALE	FEMALE
GENDER:	MALE	FEMALE
____
DISABLED:	NO	YES
__

process._ __

__ selection_ __

the__ to__

prior_ __ section_ __

this__

remove__ __

Employer,__

__ _ _

RACE/ETHNICITY (Please select all that apply to you):

American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America).

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black: (not of HISpanic origin): A person having origins in any of the black racial groups.

Hispanic or Latino: A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish origin.

Native Hawaiian or Other Paciﬁc Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Paciﬁc Islands.

White (not of Hispanic origin): A person having origins in any of the original peoples of Europe, North Africa, or Middle East.

Multiracial: A person having origins in more than one racial group.



▼ Michigan 0999D PDF Form

Document Specs

Fact Name	Details
Form Title	Michigan Department of Transportation Employment Application
Form Number	0999D
Effective Date	January 2007
Submission Address	Office of Human Resources, 934 Bridge Plaza, Sault Ste. Marie, Michigan 48783
Fax Number	(906) 635-0540
Equal Opportunity Employer	This form is used by an employer committed to equal opportunity.
Assistance for Disabilities	Reasonable accommodations may be provided for applicants with disabilities.
Governing Law	Michigan Persons with Disabilities Civil Rights Act
Certification Requirement	Applicants must certify the truthfulness of the information provided.

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