Shadonn J.

Jenkins Nursing & Rehabilitation Center

Employment Application
Shadonn J. Jenkins Nursing & Rehabilitaion Center is an equal opportunity
employerand will not discriminate against any applicant on the basis ofany
characteristic that is protected by state or federal law. Michigan law require that
person with a disability or handicap requiring accommodation to perform the essential
duties of the job must notify the employer in writing 182 of the days of the date that
need is known or should have been known.

Applicant's Information
Date of Application:___/___/____
Date you Can Start:___/___/____

Name (____________(Last),_____________(First),___________(M.I)
Date of Birth: (Day)_______, (Month)________, (Year)_________
Social Security #:_______-______-________
Mailing Address:_____________________________(ex. Apt., Street)
Country(not county):________ Zipcode:____________
City:_____________________State:___________________
Email Address:____________________________________
Daytime Telephone Number: (
Additional/Cell Number: (

) ________ _ _________
) ________ _ ___________

-----------------------------------------------------------------------------------------------

School Visit: I have scheluled a visit on_______________(Date)

Are you 18 years or older? _______ Yes _______ No
Are you lawfully entitled to be employed in the Unites States?
_______Yes

_______No

Are there any hours or days of the week you cannot work?_______
_______ If so, when? _______________________________________
Salary Desired_________________Type of Employment:__________
Full-time_____
Part-time_____
Are you employed now?________
May we contact your present employer?_________
Did you ever apply to this Company before?______ Where?_______
Under what name?_________________ When?_________________
Names of friends or relatives who preently work for this company:
__________________________________________________________
__________________________________________________________
_______________________________________________________.
Emergency Contact Information
Name:_________________________Home Phone:_______________
Address:______________________ Work Phone:________________
City:_______________ State:_______________ Zip:______________
How is this person related to you?____________________________

----------------------------------------------------------------------------------------------Employment Position
Position:_________________ Date Started:_____________________
Starting Salary:_______________________
Job responsilbilities:_________________________________________
Training Requirements
Type of training
______________
______________
______________

Location/Amount of time needed Dates

_____________________________ _________
_____________________________ _________
_____________________________ _________

General
List any foreign languages you speak and check your level of fluency:
__________ ______Minimal ______Fluent ______Read______Write
__________ ______Minimal ______Fluent ______Read______Write
__________ ______Minimal ______Fluent ______Read______Write
__________ ______Minimal ______Fluent ______Read______Write
__________ ______Minimal ______Fluent ______Read______Write
(IF YOU SPEAK OR HAVE ANY MORE FLUENCY IN FOREIGN LANGUAGES, FOR EXTRA SPACE OF MORE.. TYPE ON
SEPERATE SHEET OF PAPER AND ATTACH TO APPLICATION). LABEL IT AS "GENERAL".

Security
Have you ever been bonded? _______Yes
______No
If so,
explain:____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
_.

IF IN NEED OF EXTRA SPACE, PLEASE FEEL FREE TO ATTACH TO SEPARTE SHEETS OF PAPER. YOU ARE MORE
THAN WELCOME TO PROVIDE LEGAL DOCUMENTATION OF PROOF OF CLEARANCE OR EXPLANATION OF
HAPPENINGS.

Have you been convicted of a felony within the past 5 years?

_______Yes
_______No
If yes,
explain:____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
_.
IF IN NEED OF EXTRA SPACE, PLEASE FEEL FREE TO ATTACH TO SEPARTE SHEETS OF PAPER. YOU ARE MORE
THAN WELCOME TO PROVIDE LEGAL DOCUMENTATION OF PROOF OF CLEARANCE OR EXPLANATION OF
HAPPENINGS.

Military
Have you served in the military? _______Yes
_______No
Served from _____/______/______ to _____/______/______
Rank:____________
Do you have any military commitment, including National Guard service
that would influence your work schedule?
_______Yes
_______No
If yes,
explain:____________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
_.
IF IN NEED OF EXTRA SPACE, PLEASE FEEL FREE TO ATTACH TO SEPARTE SHEETS OF PAPER. YOU ARE MORE
THAN WELCOME TO PROVIDE LEGAL DOCUMENTATION OF PROOF OF CLEARANCE OR EXPLANATION OF
HAPPENINGS.

Are you a Vietnam veteran? _______Yes

Are you a disabled verteran? _______Yes

_______No
_______No

Are you a special disabled veteran? _______Yes

_______No
Reasonable Accommodations: In the event you believe you will need
reasonable accomodations to assist you in performing your job, please
contact your supervisor or human resources coordinator.
Education
*Elementary School*:
Name and Address_______________________________________________
No. of Years Attended____________________
Did you Graduate?_______________________
Subject/Major___________________________
*High School*:
Name and Address_______________________________________________
No. of Years Attended____________________
Did you Graduate?_______________________
Subject/Major___________________________
*College*:
Name and Address_______________________________________________
No. of Years Attended____________________
Did you Graduate?_______________________
Subject/Major___________________________
*College*:
Name and Address_______________________________________________
No. of Years Attended____________________
Did you Graduate?_______________________
Subject/Major___________________________
*Specialized Training, manage experience, equipment operation or
qualifications*:
Name and Address_______________________________________________
No. of Years Attended____________________
Did you Graduate?_______________________
Subject/Major___________________________
*Specialized Training, manage experience, equipment operation or
qualifications*:
Name and Address_______________________________________________
No. of Years Attended____________________
Did you Graduate?_______________________
Subject/Major___________________________

References: Three Individuals Not Related To You, Whom You Have Known For At
Least One Year:
NAME

ADDRESS AND TELEPHONE

YEARS AQUAINTED RELATIONSHIP

(1)________________________________________________________________
NAME

ADDRESS AND TELEPHONE

YEARS AQUAINTED RELATIONSHIP

(2)________________________________________________________________
NAME

ADDRESS AND TELEPHONE

YEARS AQUAINTED RELATIONSHIP

(3)________________________________________________________________

CURRENT AND FORMER EMPLOYERS: (MOST RECENT ONE FIRST)

To:Date
Month/Date:___/___/____
From:Date
Month/Date:___/___/____
Name, Address and Telephone No. of Employer
_______________(Name) _________________(# of Employer)
________________________________(Address)
Salary Starting/Ending:___________________/__________________
Last Position held/Responsibilities:____________________________
Reason for
Leaving:____________________________________________________
________________________________________________________.

To:Date
Month/Date:___/___/____
From:Date
Month/Date:___/___/____
Name, Address and Telephone No. of Employer

_______________(Name) _________________(# of Employer)

________________________________(Address)
Salary Starting/Ending:___________________/__________________
Last Position held/Responsibilities:____________________________
Reason for
Leaving:____________________________________________________
________________________________________________________.

To:Date
Month/Date:___/___/____
From:Date
Month/Date:___/___/____
Name, Address and Telephone No. of Employer
_______________(Name) _________________(# of Employer)
________________________________(Address)
Salary Starting/Ending:___________________/__________________
Last Position held/Responsibilities:____________________________
Reason for
Leaving:____________________________________________________
________________________________________________________.
PLEASE READ THE FOLLOWING STATEMENT CAREFULLY BEFORE
SIGNING TO INDICATE YOUR UNDERSTANDING:
I understand that, prior to being offered employment, I may be
requesten to take an employment examination. In the event that I have
a disability that will affect my ability to take the test, I will so inform
The Shadonn J. Jenkins Nursing & Rehabilitation Center prior to the
administration of the test so that a reasonable accomodation can be
made. , reserves the right to require medical documentation regarding
the need for accomodation.

I certify that the facts contained in this application are true and
complete to the best of my knowledge and understand that, if
employed, falsified statements on this application may result in
termination.
I understand and agree that, if hired, my employment is no
definite period and may, regardless of the date of payment wages and
salary, be terminated with or without cause, at any time, with or
without notice.
If you have any questions regarding the following statements,
please ask prior to signing.
The Shadonn J. Jenkins Nursing & Rehabilitation Center does not
discriminate in hiring or employment on the basis of race, color,
religion, age, disability, veteran status, or status within any group
protected by federal, state, or local law. No questions on this
application are intended to be used for any such discriminatory
purpose.
This application will be given every consideration, but our receipt of it
does not imply that you will be offered employment. By signing
submitting this form, you authorize investigation of all statements
contained herein and the references and employers listed to give us
any and all information concerning your previous employment and any
pertinent information they may have, personal or otherwise, and
release The Shadonn J. Jenkins Nursing & Rehabilitation Center
from any liability for any damages that may result from the utilization
of such information. You consent to take a physical examination, and
such future physical examinations that we may required at times and
places designated by us. You understand that an offer of employment
maybe contingent on passing the physical examination that relates to
the essential duties that you would be required to perform.
By submitting the form below you certify that all statements made by
you on this application are true and complete to the best of your
knowledge and that you understand that misrepresentations or

omissions may be cause for rejection, or may be cause for subsequent

dismissal if you are hired.
By submitting the form below below, you understand that nothing
contained in the application or in the interview process is intended to
create an employment contract between you (the applicant) and The
Shadonn J. Jenkins Nursing & Rehabilitation Center . Should this
application result in your employment, you have a right to terminate
your employment at any time and for any reason and The Shadonn J.
Jenkins Nursing & Rehabilitation Center retains a similar right. You
further understand that no representative of The Shadonn J. Jenkins
Nursing & Rehabilitation Center other than {Nursing
Director/Administrative Staff} has any authority to enter into any
agreement with you for any specified period of time or to guarantee
any personal benefit. You further acknowledge this entire statement
applies to the period prior to, during and after any period of
employment.
I hereby acknowledge that I have read, understand, and agree to the
above statements.
AUTHORIZATION
I certify that the facts contained in this form are true and complete
tothe best of my knowledge and understand that if employed,
falsifiedstatements on this form will be grounds for dismissal.
X_______________________ EMPLOYEE SIGNATURE
X_______________________ (PLEASE PRINT NAME)
DATE ___/___/____*
Employers spcifically excepted______________________________
----------------------------------------------------------------------------------------------For Employer Use Only
Interviewed By_______________________Date________________

Hired: ______ YES ______ NO ___/___/____

PENDING......
Starting Date:___/___/____ Position:________________
Wage:__________________
copyright 2013 The Shadonn J. Jenkins Nursing & Rehabilitation
Center