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Job Application

Section I: Equal Employment Opportunity Employer

Mill Creek Inc. is an equal opportunity employer. It is the policy of this organization not to discriminate on the basis of race, sex, religion, national origin, martial status, age, weight, height, color, disability or verertan status 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: Applicants Personal Information

State: Zip Code:
XXX-XX- (last 4 digits)   
YesNo

YesNo

   
YesNo
(Answering "yes" to this inquiry will not automatically disqualify you.)
YesNo
(Answering "yes" to this inquiry will not automatically disqualify you.)
YesNo
YesNo
YesNo

 

Section III: Availability and Interests in Work

Assisted Living orMemory Care?
(Please check which Section you are applying to work in)
YesNo
Full TimePart Time
MorningAfternoonEvening
MorningAfternoonEvening
MorningAfternoonEvening
MorningAfternoonEvening
MorningAfternoonEvening
MorningAfternoonEvening
MorningAfternoonEvening

 

Section IV: Education


Name, Street, City, State
YesNo

Name, Street, City, State
YesNo


Name, Street, City, State
YesNo

 

Section V: Professional Licenses, Certifications and Credentials

Do you have any of the following licenses or certifications?

YesNo
YesNo

YesNo

 

Section III: Section VI: Employment History

(Please start with current or most recent employer)

   
   
   

   
   
   
  

   
   
  
  

YesNo
If No, Why?

Name, Title, Phone
YesNo

Name, Title, Phone
YesNo

 

Section VII: References

Please give the names of 2 personal references from persons not related to you, whom you have known for at least 1 year:

   
   

   
   

Please give the names of 2 professional references from supervisors, managers, administrators, or executive directors form whom you have worked for:

   
   

   
   

 

Section VIII: Consent

I hereby give you my permission to contact above employers, references, educational, licensing , and credentialing and certificate institutions to verify the items I listed above. I hereby release Mill Creek Inc. and the above referenced organization, referenced persons and employers from all claims, liability and damages that may result from furnishing this information to you. I consent to releasing any information relating to my job performance, which is documented in my personal file. In the event that a prior employee or other organization is obligated to provide any written notice to me regarding the disclosure of informational to Mill Creek Inc., I hereby waive the 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 and 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 Mill Creek 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 this 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 employees, and hereby release any prior employers from all claims, liability and damages that may result from furnishing this information to you.

   

I 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.

   

 

Section IX: At Will Status

In consideration of my employment, I agree to conform to the policies, rules and regulations of Mill Creek, Inc. I understand and agree that my employment and compensation are for no definite 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 Mill Creek Inc. or myself.

   

This application will be kept on file for 3 months. You need to complete another application to be reconsidered after this date.


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