WHY CHOOSE WOODLAND ASSISTED LIVING & CONTINUING CARE COMMUNITY:
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(Note: * required fields.)
Woodland Assisted Living & Continuing Care is an equal opportunity employer. It is the policy of this organization not to discriminate on the basis of race, sex, religion, national origin, marital status, age, weight, height, color, disability or veteran 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.
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.
Full Name:*
Email:*
Present Address:*
City:*
State:*
Zip Code:*
Phone:*
Last 4 digits of Social Security Number:*
Are you 18 years or older?*—Please choose an option—YesNo
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
For which position have you applied?*
Are you interested in full-time or part-time work?* Full TimePart Time
On which days and shifts are you AVAILABLE to work?
Monday
MorningAfternoonEvening
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
On what date are you available to start work?*
High School Name, Street, City, State
Did you graduate? YesNo
College Name, Street, City, State
If yes, what degree(s) did you obtain?
Business or Trade School Name, Street, City, State
Do you have any of the following licenses or certifications?
Certified Nurses Aid YesNo
If yes, please indicate your license number:
Nursing License YesNo
Other Job related licenses, certifications or credentials YesNo
If yes, please provide details:
(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:
May we contact your current supervisor or manager? YesNo
If No, Why?
If Yes, who should we call? Name, Title, Phone
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:
Please give the names of 2 PROFESSIONAL references from supervisors, managers, administrators, or executive directors form whom you have worked for:
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 Woodland Assisted Living & Continuing Care 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 Woodland Assisted Living & Continuing Care, 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 Woodland Assisted Living & Continuing Care, 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.
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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