Job Application

Section I: Equal Employment Opportunity Employer

Straits Area Assisted Living is an equal opportunity employer. It is the policy of this organization not to discriminate on the basis of race, sex, religion, national origin, martial status, age, weight, height, color, disability or verertan status in the hiring, promotion, compensation or discipline of employees.

If you are a person with a disability, you may request any needed reasonable accommodation to participate in the application process or interview process. Michigan law requires that a person with a disability or handicap requiring accommodation for employment must notify the employer in writing within 182 days after the need is known.

Section II: Pre-Employment/Employment Substance Screening

It is the policy of the employer to maintain a drug and alcohol free environment. The employer reserves the right to require new hires to submit to a substance screen as one of the contingencies established in the conditional job offer. The employer has a zero tolerance for the use and/or abuse of drugs and/or of alcohol.

Section III: Applicant Information

Name

Present Address

City

State

Zip

Phone

Social Security Number (last 4 digits):

Are you 18 years or older?

Can you perform the duties of the job for which you are applying with or without accommodation?

Yes No

If No, please explain:

Do you have any relatives or a spouse employed by this organization?

Yes No

If Yes, Please provide names:

Name and address of person to be notified in case of an emergency:

First and last name:

Phone number:

Have you ever been convicted of a crime?
(Answering "yes" to this inquiry will not automatically disqualify you.)

Yes No

Are there any pending felony charges against you?
(Answering "yes" to this inquiry will not automatically disqualify you.)

Yes No

Have you ever worked for this organization in the past?

Yes No

If yes, did you work under a different name?

Yes No

If yes, please list Name(s)

Do you have a valid driver's license?

Yes No

Section IV: Availability and Interests in Work

For which position have you applied?*

Are you interested in full-time or part-time work?

Full-Time Part-Time

On which days and shifts are you AVAILABLE to work?

MONDAY:

Morning Afternoon Evening

TUESDAY:

Morning Afternoon Evening

WEDNESDAY:

Morning Afternoon Evening

THURSDAY:

Morning Afternoon Evening

FRIDAY:

Morning Afternoon Evening

SATURDAY:

Morning Afternoon Evening

SUNDAY:

Morning Afternoon Evening

On what date are you available to start work?

Section V: Education

High School

Did you graduate?

Yes No

College

Did you graduate?

Yes No

If yes, what degree(s) did you obtain?

Business or Trade School

Did you graduate?

Yes No

If yes, what degree(s) did you obtain?

Section VI: Professional Licenses, Certifications and Credentials

Do you have any of the following licenses or certifications?

Certified Nurses Aid

Yes No

If yes, please indicate your license number:

Nursing License

Yes No

If yes, please indicate your license number:

Other Job related licenses, certifications or credentials

Yes No

If yes, please provide details:

Section VII: Employment History

(Please start with current or most recent employer)

Company:

Phone Number:

Address:

Name of Supervisor:

Position Title:

Reason for Leaving:

Employment Dates: (Month/Year)

From:

To:

Hourly Pay:

From:

To:

Company:

Phone Number:

Address:

Name of Supervisor:

Position Title:

Reason for Leaving:

Employment Dates: (Month/Year)

From:

To:

Hourly Pay:

From:

To:

Company:

Phone Number:

Address:

Name of Supervisor:

Position Title:

Reason for Leaving:

Employment Dates: (Month/Year)

From:

To:

Hourly Pay:

From:

To:

May we contact your current supervisor or manager?

Yes No

If No, Why?

If Yes, who should we call?

Section VIII: References

Personal:

Please give the names of 2 PERSONAL references from persons not related to you, whom you have known for at least 1 year:

Name:

Phone:

Years Known:

Name:

Phone:

Years Known:

Professional:

Please give the names of 2 PROFESSIONAL references from persons not related to you, whom you have known for at least 1 year:

Name:

Phone:

Years Known:

Name:

Phone:

Years Known:

Section IX: Consent

I hereby give you my permission to contact the above employers, references, educational, licensing, and credentialing and certification institutions to verify the items I listed above. I hereby release Besser Senior Living and the above referenced organization, reference persons and employers from all claims, liability and damages that may result from furnishing this information to you. I consent to releasing any information relating to my job performance, which is documented in my personnel file. In the event that a prior employer or other organization is obligated to provide any written notice to me regarding the disclosure of information to Besser Senior Living, I hereby waive the obligation and expect no written notice of disclosure of my personal information.

I also understand that because of the nature of my job and licensing requirements, I hereby consent to the release of this application or portions of this application to representatives of the Department of Human Services, Department of Community Health, local community mental health entities and other governmental agencies or private agencies, for all licensing or investigatory purposes and to verify information I have listed in this job application. I hereby release Besser Senior Living, The Department of Human Services, Department of Community Health, local community mental health entities and other governmental agencies or private agencies from all claims, liability, and damages that may result from furnishing this information to you.

I further specifically waive written notice and agree to the divulging of any disciplinary reports, letters of reprimand or other disciplinary action by all prior employers, and hereby release any prior employers from all claims, liability and damages that may result from furnishing this information to you.

Application Signature:

Date:

I certify that all of the information provided on this application is true, complete and correct.
I further understand and agree that any falsification, misrepresentation or omission of fact on this application or in any interviews or pre-employment process are grounds for disqualification for consideration for employment or termination of employment if the discovery Is made after employment begins.

Application Signature:

Date:

This application will be kept on file for 3 months. You need to complete another application to be reconsidered after this date.

Your Bridge to Exceptional Care!

Job Application

Section I: Equal Employment Opportunity Employer

Section II: Pre-Employment/Employment Substance Screening

Section III: Applicant Information

Section IV: Availability and Interests in Work

Section V: Education

Section VI: Professional Licenses, Certifications and Credentials

Section VII: Employment History

Section VIII: References

Personal:

Professional:

Section IX: Consent