Employment Application Employment Application Personal Information: Last Name * First Name * Middle name * Phone Number (area code) * Address (No. and Street) * City * State * Zip Code (9 digit) * Have you lived in Michigan for the past 3 years or longer? * Yes No If hired, can you provide the documents required to prove that you are legally able to work in the U.S.? * Yes No Have you even been convicted for any violation of the law other than minor traffic violations? * Yes No If yes, give details * Are there any felony charges pending against you? * Yes No If yes, give details * Note: Criminal history checks/fingerprinting will be made, per State of Michigan Have you previously worked for MIDLAND KING’S DAUGHTERS HOME? * Yes No If so, give dates * Are you willing to work overtime as required? * Yes No Are you willing to take a drug test? * Yes No Are you willing to work shifts as required? * Yes No Type of work desired * Full time Part time Casual Position desired * Do you have any illness or physical limitations that would prevent you from performing the job duties for which you have applied? * Yes No Date available to start * Are you a high school graduate? * Yes No Education level attained * Work Experience: List all employment history, most recent first. Work Block Employer Name * Address * Dates employed * Phone number * May we contact employer? * YesNo Position * Duties * Supervisor * Hours worked per week * Reason for leaving * Work Block Employer Name * Address * Dates employed * Phone number * May we contact employer? * YesNo Position * Duties * Supervisor * Hours worked per week * Reason for leaving * Work Block Employer Name * Address * Dates employed * Phone number * May we contact employer? * YesNo Position * Duties * Supervisor * Hours worked per week * Reason for leaving * plus1 Add Work Experience minus1 Remove References Please list three references. References Block Name * Address * Phone number * Years known (1 year minimum) * References Block Name * Address * Phone number * Years known (1 year minimum) * References Block Name * Address * Phone number * Years known (1 year minimum) * I understand that employment by this facility will be on an “at will” basis except as modified for some positions by a union (SEIU) contract. If employed by King’s Daughters, I agree to abide by its rules and regulations. I acknowledge that the information I have furnished is correct to the best of my knowledge and understand that misstatement or omission of this information could be grounds for disciplinary action to include retraction of employment offer or dismissal, if employment has taken place. I authorize this facility to contact any and/or all of my references for full information, and authorize you to check my local, state, and/or national police record, including fingerprints,at any time. As a condition of employment or continuation of employment, I agree to immediately report to the Home’s administration if I am arrested or convicted for any of the following offenses: any felony or attempted felony, or these misdemeanors--- abuse, neglect, assault, battery, criminal sexual conduct, fraud/theft against a vulnerable adult, or the possession or delivery of a controlled substance. AN INDIVIDUAL WHO KNOWINGLY PROVIDES FALSE INFORMATION REGARDING CRIMINAL CONVICTIONS ON A STATEMENT FOR CONDITIONAL EMPLOYMENT OR CLINICAL PRIVILEGES IS GUILTY OF A MISDEMEANOR PUNISHABLE BY IMPRISONMENT FOR NOT MORE THAN 90 DAYS OR A FINE OF NOT MORE THAN $500.00 OR BOTH. I agree to take a physical examination and/ or drug testing at any time, at the request of this facility and I agree that the examining physician may disclose the findings to this facility or an authorized agent of this facility. Check this box to agree to the terms above. * I agree. If you are human, leave this field blank.
