Application for Employment- Online submission
Michigan Home Healthcare, Inc.
Michigan Home Healthcare, Inc. policy requires that employment, training and development, compensation, promotion and all other conditions of employment be provided without unlawful discrimination on the basis of race, creed, color, age, handicap, disability, citizenship, national or ethnic origin or any other basis as prohibited by law.
LAST NAME:
FIRST NAME:
AFTER REVIEWING THE POSITION'S JOB DESCRIPTION, ARE YOU ABLE TO PERFORM THE ESSENTIAL FUNCTIONS OF THE POSITION, WITH OR WITHOUT ACCOMMODATION(S)?
IF YOU CAN PERFORM THE ESSENTIAL DUTIES ONLY WITH ACCOMMODATION, HOW WOULD YOU PERFORM THOSE DUTIES AND WITH WHAT ACCOMMODATION(S)?
WHAT IS YOUR AVAILABILITY?
INDICATE THE DATE THAT YOU WILL BE AVAILABLE TO BEGIN WORK:
IF YOU ARE UNDER 18 YEARS OF AGE, CAN YOU PROVIDE PROOF OF YOUR ELIGIBILITY TO WORK?
ARE YOU LEGALLY ELIGIBLE TO WORK IN THE USA?
POSITION YOU ARE APPLYING FOR:
ALTERNATE PHONE AND/OR CELL PHONE NUMBER:
HOME PHONE NUMBER:
ADDRESS, CITY, STATE, ZIP:
OTHER NAMES YOU HAVE USED:
MIDDLE INITIAL:
HOW WERE YOU REFERRED TO OUR AGENCY?
IF APPLYING FOR A POSITION THAT REQUIRES TRAVEL, DO YOU HAVE ACCESS TO DEPENDABLE TRANSPORTATION WITH AUTO INSURANCE AND A VALID MOTOR VEHICLE OPERATOR'S LICENSE?
WHAT WAGE/SALARY RANGE ARE YOU REQUESTING FOR THIS POSITION?
HAVE YOU EVER BEEN CONVICTED OF A CRIME, FELONY OR MISDEMEANOR?
HHAVE YOU EVER BEEN EMPLOYED AT OUR AGENCY? IF YES, PROVIDE DATES
In consideration for employment, Michigan Home Healthcare, Inc. is required by state law to obtain a copy of your criminal history. Except as required by state law, a coniction record will not necessarily be a bar to employment. Factors such as age, time of offense, the seriousness/nature of the violation and subsequent rehabilitation will be taken into account.
EDUCATION
NAME AND LOCATION
YEARS COMPLETED
DID YOU GRADUATE
DEGREES OBTAINED AND/OR MAJOR
High school:
College:
Other:
List any skills, certifications or other credentials that would qualify you to work for our organization:
PROFESSIONAL LICENSURE/CERTIFICATION
TYPE: (RN, LPN, PT, MSW, CNA, ETC.
LICENSE NUMBER
EXPIRATION DATE
STATE OF ISSUE
Have you ever had disciplinary action taken against you your professional licensure and/or certification?
If yes, please explain:
Do you belong to a professional, trade, business, or civic association?
If yes, please list here:
THREE PERSONAL REFERENCES (Please do NOT include people who are related to you)
NAME
RELATIONSHIP
PHONE NUMBER
YEARS KNOWN
EMPLOYMENT HISTORY (Please list your employers, starting with the most recent. Include job-related military experience
Employer, address, telephone & supervisor's name
Job responsibilities, ending wage
From/To (use month & year)
Reason For Leaving (may we contact this employer?)
Do you have friends or relatives who currently work for MICHIGAN HOME HEALTHCARE, INC.?
Have you been convicted of or pleaded guilty to any moving violations within the past twelve (12) months?
If yes, please explain:
Please read the statement below and sign it at the bottom (your typed first and last name will serve as your signature)
I agree that I have been informed of the requirement of the work for which I am applying and that the information on this application and corresponding attachments, if any, are correct and complete to the best of my knowledge and agree that falsified information or significant omissions may disqualify me from further consideration for employment and may result in immediate termination of employment if discovered at a later date.
I understand and acknowledge that my employment is "at will" and that employment is by mutual agreement of Michigan Home Healthcare, Inc. and myself and I may resign at any time and Michigan Home Healthcare, Inc. may terminate my employment at any time, with or without cause, for any reason.
I understand that, if offered employment, Michigan Home Healthcare, Inc. will make or cause an agency on its behalf to make inquiries, including but limited to criminal history, public records, experience, or other qualifications of employment, including reasons for termination of past employment. I agree that my authorization here within releases Michigan Home Healthcare, Inc. and its agent from any and all liability, from all companies, agencies, officials, officers, employees, and other persons who, in good faith, provide to us the above-mentioned information as requested in order to successfully complete a background investigation.
I understand that if I am offered employment by Michigan Home Healthcare, Inc. a medical examination is required, and my employment is conditional on the satisfactory outcome of that medical examination. I also understand that if I am offered employment by Michigan Home Healthcare, Inc. I must provide all the required information requested in order to be considered for employment. I also understand that Michigan Home Healthcare, Inc. will make reasonable accommodation to the known physical or mental limitations of a qualified applicant or employee with a disability unless the accommodation would cause an undue hardship on the operation of Michigan Home Healthcare, Inc., or the individual would pose a direct threat to the health or safety of himself/herself or of others that cannot be eliminated or reduced below the level of a direct threat by reasonable accommodation which does not cause undue hardship to Michigan Home Healthcare, Inc.
I agree to take a drug and alcohol test if I have a worker's compensation injury while I am your employee. I agree, if employed by you, that if I ever make claims against you for personal injuries, upon your request, I shall submit to examinations by physicians of your selection. I will hold Michigan Home Healthcare, Inc. harmeless from any claims, including, but not limited to, personal injury or illness as a result of my providing false or misleading information on this application.
I understand that this is an Application for Employment only, and that I have not been offered employment by Michigan Home Healthcare, Inc.
I authorize persons, schools, previous employer(s) and organizations named in this application (and any accompanying attachments (if any) to provide any relevant information to Michigan Home Healthcare, Inc. that may be required to arrive at an employment decision.
Signature of Applicant:
Date:
