ApplicationSection I: Equal Employment Opportunity EmployerLife Center, Inc. is an equal opportunity employer. It is the policy of this organization not to discriminate on the basis of race, sex, sexual orientation, religion, national origin, marital status, age, weight, height, color, disability, veteran status or genetic information and/or testing 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: Applicant’s Personal InformationFirst Name*Middle InitialLast Name*Maiden/OtherAddress*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip Code*Home Phone*Cell PhoneSocial Security # (Last 4 Digits)*Email* Are you 18 years of age or older? Yes NoDo you have a High School Diploma or GED? Yes NoCan you perform the duties of the job for which you are applying with or without accommodation? Yes NoIf no, please explain:Have any abuse, neglect or exploitation charges been substantiated against you by Adult or Child Protective Services? Yes NoIf yes, please explain:Have you had any recipient rights complaints substantiated against you by the Office of Recipient Rights, any Community Mental Health agency or their designee? Yes NoIf yes, please explain:Have you ever been convicted of a crime?(Answering “yes” to this inquiry will not automatically disqualify you for employment.) Yes NoIf yes, please explain:Are there any pending criminal felony charges against you?(Answering “yes” to this inquiry will not automatically disqualify you.) Yes NoIf yes, please explain:Have you ever worked for this organization in the past? Yes NoIf so, did you work under a different name? Yes NoIf yes, is any additional information pertaining to a different name necessary to check your work record? Yes NoIf yes, please explain:The position for which you are applying requires you to drive. Do you have a valid driver’s license? Yes NoDo you have access to a vehicle for use during work hours? Yes NoIs the vehicle you are using for work insured as required by state law? Yes NoSection III: Availability and Interests in WorkFor which position are you applying?Are you interested in full-time or part-time work? Full-time Part-time EitherFor which counties would you like to be considered? Macomb Oakland Wayne GeneseeOn which days and shifts are you available to work?Monday Morning Afternoon MidnightTuesday Morning Afternoon MidnightWednesday Morning Afternoon MidnightThursday Morning Afternoon MidnightFriday Morning Afternoon MidnightSaturday Morning Afternoon MidnightSunday Morning Afternoon MidnightOn what date are you available to start work?Note: Availability and Interest preferences listed above are considered at the time of application, but are not meant as a guarantee of assigned location or schedule.Section IV: EducationHighschoolNameStreetCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDid you graduate? Yes NoCollegeNameStreetCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDid you graduate? Yes NoIf yes, what degree(s) did you obtain?OtherNameStreetCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificDid you graduate? Yes NoIf yes, what degree(s) or certificate(s) did you obtain?Section V: Employment History (Please start with present or most recent employer)1.) Company NameTelephoneAddressStart Date (mm/yyyy)End Date (mm/yyyy)Position TitleHourly Pay StartHourly Pay LastName of SupervisorReason for Leaving2.) Company NameTelephoneAddressStart Date (mm/yyyy)End Date (mm/yyyy)Position TitleHourly Pay StartHourly Pay LastName of SupervisorReason for Leaving3.) Company NameTelephoneAddressStart Date (mm/yyyy)End Date (mm/yyyy)Position TitleHourly Pay StartHourly Pay LastName of SupervisorReason for LeavingMay we contact your current supervisor or manager? Yes NoIf no, why?If yes, who should we call? (Name, Title, Phone)Section VI: Professional Licenses, Certifications and CredentialsDo you have any of the following licenses or certifications?Certified Nurse Aid Yes NoIf yes, please indicate your license number:Nursing License Yes NoIf yes, please indicate your license number:Other job-related licenses, certifications or credentials Yes NoIf yes, please indicate your license number:Section VII: ConsentI hereby give you my permission to contact the above employers, educational, licensing, credentialing and certification institutions to verify the items I listed above. I hereby release Life Center, Inc. and the above referenced organizations, reference persons and employers from all claims, liability and damages that may result from furnishing the 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 Life Center, Inc., I hereby waive that 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 or 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 Life Center, Inc., 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 the 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 the information to you.Applicant Signature*Date* MM slash DD slash YYYY Section VIII: AttestationI 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.Applicant Signature*Date* MM slash DD slash YYYY READ CAREFULLY BEFORE SIGNING:I agree that, in consideration for Life Center, Inc. considering my application for employment, any claim or lawsuit that I may have relating to either my application for employment or, if hired, to my actual employment or service with Life Center, Inc. or any of its subsidiaries, must be filed no more than six (6) months after the date of the employment action that is the subject of the claim or lawsuit. I understand that by agreeing to this provision, I waive any statute of limitations to the contrary that may have been available to me pursuant to Michigan’s Elliott-Larsen Civil Rights Act or any other state, federal, or local statute or ordinance, with the exception of any statute or ordinance that provides a shorter statute of limitations such as Michigan’s Whistleblowers’ Protection Act, which provides for a ninety day statute of limitations.Applicant Signature*Date* MM slash DD slash YYYY Section IX: At-Will StatusIn consideration of my employment, I agree to conform to the policies, rules and regulations of Life Center, Inc. I understand and agree that my employment and compensation are for no definite period 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 Life Center, Inc. or myself.Applicant Signature*Date* MM slash DD slash YYYY Employer SignatureDate MM slash DD slash YYYY Please note: This application will be kept on file for 12 monthsThis site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.CommentsThis field is for validation purposes and should be left unchanged.
