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 Full Name: Email: Present Address: City: State: Zip Code: Phone: Social Security Number: XXX-XX- (last 4 digits) Are you 18 years or older?—Please choose an option—YesNo Can you perform the duties of the job for which you are applying with or without accommodation?YesNo If No, please explain: Do you have any relatives or a spouse employed by this organization?YesNo If Yes, Please provide names: Name and address of person to be notified in case of an emergency: First & Last Name: Phone Number: Have you ever been convicted of a crime?YesNo (Answering "yes" to this inquiry will not automatically disqualify you.) Are there any pending felony charges against you?YesNo (Answering "yes" to this inquiry will not automatically disqualify you.) Have you ever worked for this organization in the past?YesNo If yes, did you work under a different name?YesNo If yes, please list Name(s) Do you have a valid driver's license?YesNo Section III: Availability and Interests in Work Are you applying for a position in Assisted Living orMemory Care? (Please check which Section you are applying to work in) For which position have you applied? Have you been given a job description for this position?YesNo Are you interested in full-time or part-time work?Full TimePart Time MonMorningAfternoonEvening TueMorningAfternoonEvening WedMorningAfternoonEvening ThuMorningAfternoonEvening FriMorningAfternoonEvening SatMorningAfternoonEvening SunMorningAfternoonEvening On what date are you available to start work? Section IV: Education High School Name, Street, City, State Did you graduate?YesNo College Name, Street, City, State Did you graduate?YesNo If yes, what degree(s) did you obtain? Business or Trade School Name, Street, City, State Did you graduate?YesNo If yes, what degree(s) did you obtain? Section V: Professional Licenses, Certifications and Credentials Do you have any of the following licenses or certifications? Certified Nurses AidYesNo If yes, please indicate your license number: Nursing LicenseYesNo If yes, please indicate your license number: Other Job related licenses, certifications or credentialsYesNo If yes, please provide details: Section III: Section VI: Employment History (Please start with current or most recent employer) Company: Phone Number: Address: Name of Supervisor: Position Title: Reason for Leaving: Employment Dates: (Month/Year) From: To: Hourly Pay Start: Last: Company: Phone Number: Address: Name of Supervisor: Position Title: Reason for Leaving: Employment Dates: (Month/Year) From: To: Hourly Pay Start: Last: Company: Phone Number: Address: Name of Supervisor: Position Title: Reason for Leaving: Employment Dates: (Month/Year) From: To: Hourly Pay Start: Last: May we contact your current supervisor or manager?YesNo If No, Why? If yes, who should we call? Name, Title, Phone Have any of your previous employers served persons funded through community mental health (CMH) entity?YesNo If yes, which CMH entities were involved? Name, Title, Phone May we contact the employers and CMH entities that you listed above to determine whether you have ever had a recipient rights violation substantiated against you?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: Name: Address: Phone #: Years Known: Name: Address: Phone #: Years Known: Please give the names of 2 professional references from supervisors, managers, administrators, or executive directors form whom you have worked for: Name: Address: Phone #: Years Known: Name: Address: Phone #: Years Known: 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. Application Signature: Date: 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. Application Signature: Date: 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. Application Signature: Date: This application will be kept on file for 3 months. You need to complete another application to be reconsidered after this date.