Name:
*
First Name
Last Name
Have you ever used another name?
*
Address:
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone:
*
(###)
###
####
Alternate Phone:
(###)
###
####
Email:
Social Security Number:
*
Are you over 18 years of age?
*
Desired Employment:
*
Full-time
Part-time
Either
Check which days you are available to work:
*
Check which shifts you are available to work:
*
If hired, on what date can you start working?
*
Have you ever applied to work for Quality Care of Howell before?
*
Do you have any friends, relatives or acqaintances working for Quality Care of Howell?
*
If hired, would you have transportation to/from work?
*
If hired, are you willing to submit to a physical drug test and TB test before you start your employment with Quality Care?
Are you able to perform the essential functions of the job for which you are applying, either with or without reasonable accommodation?
Examples: Lift anywhere from 25-100 pounds, light housekeeping, cooking, baking, medication administration, driving a motor vehicle, reading, writing.
If no, describe the functions that cannot be performed:
Are you willing to attend training programs required by the state of Michigan AFC Licensing Division?
*
Would you be willing to cover extra shifts in the case of another employee’s absence?
*
Are you willing to work every other weekend and every other holiday?
*
Have you ever been convicted of a crime?
*
If yes, please explain:
Name:
*
City and State:
*
Did you graduate?
*
Name:
City and State:
Years Completed:
Did you graduate?
Name:
City and State:
Relevant info:
Ex: Years completed, certificate earned, graduation date.
May we contact your previous employer?
Name of your employer:
Address:
Phone:
(###)
###
####
Supervisor:
Job Title:
Reason for leaving:
List general duties performed:
May we contact your previous employer?
Name of your employer:
Address:
Phone:
(###)
###
####
Supervisor:
Job Title:
Reason for leaving:
List general duties performed:
May we contact your previous employer?
Name of your employer:
Address:
Phone:
(###)
###
####
Supervisor:
Job Title:
Reason for leaving:
List general duties performed:
If you have more jobs to include, please list them here:
Use the same format as above.
Do you have any other JOB EXPERIENCE that would help you with this job? If yes, please explain:
Summarize any specialized trainings, skills, licenses, certificates and/or characteristics of yourself that may qualify you as being able to perform job‐related functions for the position in which you are applying:
Name:
Address:
Phone:
(###)
###
####
Name:
Address:
Phone:
(###)
###
####
At-Will Employment
*
Quality Care of Howell maintains an At‐Will Employment arrangement with all employees. I understand that if hired, the employment will not be permanent; instead the employment will be At‐Will meaning that either party may terminate this agreement at any time, with or without cause, at‐will.
Dependent Care
*
If hired, I understand due to the nature of the business, (taking care of dependent people) I will have dependent people and my co‐workers relying on me to come to work, when scheduled and on time, unless I am prevented to do so because of illness or emergency. In the event I am not able to come to work, I will immediately make a reasonable attempt to find my own replacement as well as notify the administration. I further understand that, although this employment relationship is At‐Will, I am not allowed to walk away from my job and leave the residents unsupervised at any time. This can be considered a vulnerable adult violation and appropriate action will ensue.
Physical and Mental Ability
*
I understand that due to the nature of the business; (taking care of dependent people) I must always have the physical and mental ability to do the job. If I am disabled, or become disabled, I understand that I can request the company to make reasonable accommodations to assist me, however, the company may refuse if it compromises resident care, or causes an undue hardship on the company.
Visiting After Termination
*
If hired, I understand that this facility reserves the right to refuse to allow me to come back to visit at the facility after termination of employment.
Drug & Alcohol Policy
*
I understand that prior to my acceptance of employment, and if hired, during my employment, I may be tested for the use of illegal drugs, and if found positive for use, my relationship with Quality Care of Howell will be immediately terminated. I further understand that if hired, and I am found under the influence of drugs or alcohol while at work, I may be immediately terminated.
Non-Discrimination Policy
*
I understand this company does not discriminate against applicants because of race, creed, color, religion, gender, or sexual preference, and that hiring is based on qualification, personal characteristics, background check, and interview.
Conditional Hire
*
I understand my employment status with Quality Care of Howell, if hired, is conditional until my criminal background check clears, I pass medication administration training and testing, or discovery of a criminal conviction.
