Job Application

    Section I: Equal Employment Opportunity Employer

    Teal Lake Senior Living Community 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: Applicants Personal Information

    Full Name:

    Email:

    Present Address:

    City:    State:    Zip Code:

    Phone:    Alternate, Cell:

    Social Security Number: XXX-XX- (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?YesNo

    If No, please explain:

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

    If Yes, Please provide names:

    Name and address of person to be notified in case of an emergency:
    First & Last Name:    Phone Number:

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

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

    Have you ever worked for this organization in the past?YesNo

    If yes, did you work under a different name?YesNo

    If yes, please list Name(s)

    Do you have a valid driver's license?YesNo

     

    Section III: Availability and Interests in Work

    Are you applying for a position in Resident CareDietaryHousekeepingAny Available Position?
    (Please check which you are applying to work in)

    Have you been given a job description for this position?YesNo

    Are you interested in full-time or part-time work?Full TimePart Time

    MonMorningAfternoonEvening

    TueMorningAfternoonEvening

    WedMorningAfternoonEvening

    ThuMorningAfternoonEvening

    FriMorningAfternoonEvening

    SatMorningAfternoonEvening

    SunMorningAfternoonEvening

    On what date are you available to start work?

     

    Section IV: Education

    High School
    Name, Street, City, State

    Did you graduate?YesNo

     

    College
    Name, Street, City, State

    Did you graduate?YesNo

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

     

    Business or Trade School
    Name, Street, City, State

    Did you graduate?YesNo

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

     

    Section V: Professional Licenses, Certifications and Credentials

    Do you have any of the following licenses or certifications?

    Certified Nurses AidYesNo
    If yes, please indicate your license number:

    Nursing LicenseYesNo
    If yes, please indicate your license number:

    Other Job related licenses, certifications or credentialsYesNo
    If yes, please provide details:

     

    Section III: Section VI: 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
    Start:      Last:

    Company:    Phone Number:

    Address:    Name of Supervisor:

    Position Title:    Reason for Leaving:

    Employment Dates: (Month/Year)
    From:      To:

    Hourly Pay
    Start:      Last:

    Company:    Phone Number:

    Address:    Name of Supervisor:

    Position Title:    Reason for Leaving:

    Employment Dates: (Month/Year)
    From:      To:

    Hourly Pay
    Start:      Last:

    May we contact your current supervisor or manager?YesNo

    If No, Why?

    If yes, who should we call?
    Name, Title, Phone

    Have any of your previous employers served persons funded through community mental health (CMH) entity?YesNo

    If yes, which CMH entities were involved?
    Name, Title, Phone

    May we contact the employers and CMH entities that you listed above to determine whether you have ever had a recipient rights violation substantiated against you?YesNo

     

    Section VII: References

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

    Name:   Address:

    Phone #:   Years Known:

    Name:   Address:

    Phone #:   Years Known:

    Please give the names of 2 professional references from supervisors, managers, administrators, or executive directors form whom you have worked for:

    Name:   Address:

    Phone #:   Years Known:

    Name:   Address:

    Phone #:   Years Known:

     

    Section VIII: Consent

    I hereby give you my permission to contact above employers, references, educational, licensing , and credentialing and certificate institutions to verify the items I listed above. I hereby release Teal Lake Senior Living Community and the above referenced organization, referenced 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 personal file. In the event that a prior employee or other organization is obligated to provide any written notice to me regarding the disclosure of informational to Teal Lake Senior Living Community, 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 releaseTeal Lake Senior Living Community, 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 employees, 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:

     

    Section IX: At Will Status

    In consideration of my employment, I agree to conform to the policies, rules and regulations of Teal Lake Senior Living Community I understand and agree that my employment and compensation are for no definite and may, regardless of the time and manner of my wages or salary, be terminated at will with or without cause and with or without notice at any time, at the sole discretion of Teal Lake Senior Living Community or myself.

    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.

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