APPLICATION FOR EMPLOYMENT

Position Applying For

Location

Date

First Name

Last Name

Cell phone

Email

example@example.com

Local Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Permanent Address

Street address

Street Address Line 2

CityState

Postal / Zip Code

Are you at least 18 years old?

YesNo

Have you ever been applied here before?

YesNo

If yes, give date

Date

Have you ever been employed here before?

YesNo If yes, give dates and reason for leaving

If yes, give dates and reason for leaving:

Are you legally authoirzed to work in the United States?

YesNo

Date available to start work?

Date

Days available to work, please indicate by using M, T, W, Th, F, Sat, Sun

Type of employment desired:

Full timePart time

Number of hours desired per week:

Rate of pay expected; please note that peer partner positions are volunteer. (unpaid)

Are you currently employed at a full-time job?

YesNo

How will this affect your ability to work?

Do you have any restrictions on the hours you can work?

YesNo

If yes, please explain:

Note: Affirmative answers to the following may not automatically preclude you from consideration for employment.

Have charges ever been substantiated against you for abuse, neglect, exploitation, mishandling client funds or any other recipient rights violation in an investigation by Dept. of Commerce/Dept. of Consumer and Industry Services, Family Independence Agency, a local Community Mental Health Recipient Rights Office, or any other recipient rights office?

YesNo

If yes, please explain

Have charges ever been substantiated against you for abuse, neglect, exploitation, mishandling client funds or any other recipient rights violation in an investigation by Dept. of Commerce/Dept. of Consumer and Industry Services, Family Independence Agency, a local Community Mental Health Recipient Rights Office, or any other recipient rights office?

YesNo

If yes, please explain

Have you ever been administratively determined by a federal, state, or local governmental agency to have committed any of the following?

Assault or battery?

YesNo

Abuse or Neglect

YesNo

Criminal Sexual Misconduct

YesNo

If you answered yes to any of the above, please list the nature of the offense(s), date(s) of conviction and place(s) of offense(s). Failure to complete this section accurately may be grounds for immediate termination or withdrawal of conditional job offer.

Many positions at Ready for Life require a safe driving record and the use of a vehicle. Do you have a safe driving record and proof of insurance? Please indicate Yes or No below. If no, please explain.

If you are applying to work as a direct care worker, please answer the following questions.

Have you received a copy of the job description?

YesNo

Prepare Food

YesNo

Housekeeping

YesNo

Drive

YesNo

Type a question

YesNo

Ready For Life may require a copy of all original education and training certificates to verify that you meet the requirements of any job for which you are applying.

High School diploma or GED obtained?

YesNo

(1) Name of School

Highest Level Completed

Degree Earned

Major

(2)Name of School

Highest Level Completed

Degree Earned

Major

Professional Licenses or Certifications:

Have you received training from the Michigan Department of Community Health or through the Family Independence Agency?

YesNo

If yes, explain what training:

Other current certifications such as CPR, First Aid

Summarize unique skills and qualifications you acquired from prior employment, training, or experiences that may qualify you for a job within the company.

Are you able to perform the duties of the job(s) for which you are applying with or without a reasonable accommodation?

YesNo

List your last four employers or volunteer activities, starting with the most recent.

Most recent employer

Phone

Address

Supervisor

Your job title

Dates

Date

Reason for leaving

Recent employer

Phone

Address

Supervisor

Your job title

Dates

Date

Reason for leaving

Recent employer

Phone

Address

Supervisor

Your job title

Dates

Date

Reason for leaving

Most recent employer

Phone

Address

Supervisor

Your job title

Dates

Date

Reason for leaving

Name

Phone

Phone number is:

HomeWork

Company

E-mail

example@example.com

Relationship to you

Name

Phone

Phone is:

HomeWork

Company

E-mail

example@example.com

Relationship to you

Name

Phone

Phone is:

HomeWork

Company

E-mail

example@example.com

Relationship to you

Name

Phone

Phone is:

HomeWork

Company

E-mail

example@example.com

Relationship to you

Please upload your resume and cover letter:

I have submitted the attached form to the compay for the purpose of obtaining employment. I acknowledge that the use of this form, and the filling it out does not indicate that any positions are open nor does it obligate the Company to further process my application.

My signature below attests to the fact that the information that I have provided on my application, resume, given verbally, or provied in any other materials, is true and complete to the best of my knowledge and constitues aurthority to verify all information submitted on this application. I understand that any misrepresentation or omission of any fact in my application, resume or any other matierial, or dring any interviews, can be justification for refusal of employment, or, if employed, termination from the company's employ.

I also affirm that I have not signed any kind of restrictive document creating any obligation to any former employer that would estric my acceptance of employment wit the Company in the position I am seeking.

I understand that this application is not an employment contract for any specific length of time between the Company and me, and that in the event I am hired, my employment will be "at will" and either the Company or I can terminate my employment with or without cause and with or withoutt notice at any time. Nothing contained in any handbook, manual, policy, and the like, distributed by the Company to its employees is intended to or can create an employment contract, an offer of employment or any obligation on the Company’s part. The Company may, at its sole discretion, hold in abeyance or revoke, amend, or modify, abridge, or change any benefit, policy practice, condition or process affecting its employees.

References: I hereby authorize the company and its agents to make such investigations and inquiries into my employment and educational history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools, and other persons from all liability in responding to inquires connected with my application and I specifically authorize the release of information by any schools, businesses, individuals, services, or other entities listed by me in this form. Furthermore, I authorize the company and its agents to release any reference information to clients who request such information for purposes of evaluating my credentials and qualifications.

Signature of Applicant

Date

APPLICATION FOR EMPLOYMENT

General Information

Availability

Are you able to perform the following:

Educational Background

Employment History

References

PLEASE READ CAREFULLY BEFORE SIGNING APPLICATION