Superior Health Support Systems Employment Application

Application for Employment
Applicant Name*

First NameLast Name
Applicant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Applicant Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Applicant Email*
example@example.com
How did you hear about this open position?*
Are you 18 years of age or older? (Due to licensing the only location that can employ minors is Hearthside Assisted Living)*

YesNo
Are you legally authorized to work in the United States?*

YesNo
Are you currently CPR/First aid certified?*

YesNo
Please list any other relevant certifications you currently have (CNA, MA, LPN, etc.)
If applying for an aide position, are you aware that your job duties will include personal hygiene care, including toileting and showering residents of both genders?

YesNo
Facility you are applying for:*

Hearthside Assisted Living - 1501 W 6th Ave, Sault Ste. Marie, MI 49783Merlin Home - 1703 Hyde St, Sault Ste Marie, MI 49783Pennington Home - 665 S Pleasant St, Pickford, MI 49774Harbor View Assisted Living - 200 Cunningham Street, DeTour, MI 49725White-Wiles Home - 10946 W Fair Dor Dr, Rudyard, MI 49780
Type of employment you are interested in:*

Part-timeFull-timePermanentTemporary
If seeking part time employment, how many days per week are you available*
Shifts you are available to work:*

DaysAfternoon/EveningsNightsWeekdays (M-F)Weekends (Saturday & Sunday)Fill-in as needed
Have you previously worked for Superior Health Support Systems?*

YesNo
Do you have relatives employed by this agency?*

YesNo
If yes, relatives name*
If yes, relation to above person*
EDUCATION
Please check the highest level of education completed:*

High SchoolAssociates DegreeBachelors DegreeOther
Degree held*
If you did not complete high school, do you have a high school equivalency diploma?

YesNo
If you expect to complete an educational program in the near future, please indicate the type of degree or program and the completion date expected:
EXPERIENCE

Starting with your most recent employment, please describe your knowledge, skills and abilities, which best demonstrate your qualifications for the position in which you are applying
May we contact your current employer?*

YesNo
How many employers do you have work history with? (including current employer)*

0123+
Employer 1:

Current or most recent employer
Name - Employer 1*
Address - Employer 1*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employed From - Employer 1*

MonthDayYear
Date
Employed To - Employer 1*

MonthDayYear
Date
Hours Per week - Employer 1*
Position Title - Employer 1*
Supervisor - Employer 1*

First NameLast Name
May we contact your supervisor? - Employer 1*

YesNo
Supervisor Phone Number - Employer 1*
Please enter a valid phone number.Format: (000) 000-0000.
Number and types of employees you supervised: - Employer 1*
Last salary (specify per hour, week or month) - Employer 1
Reason for leaving - Employer 1*
Duties: - Employer 1*
Employer 2:
Name - Employer 2*
Address - Employer 2*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employed From - Employer 2*

MonthDayYear
Date
Employed To - Employer 2*

MonthDayYear
Date
Hours Per week - Employer 2*
Position Title - Employer 2*
Supervisor - Employer 2*

First NameLast Name
May we contact your supervisor? - Employer 2*

YesNo
Supervisor Phone Number - Employer 2*
Please enter a valid phone number.Format: (000) 000-0000.
Number and types of employees you supervised: - Employer 2*
Last salary (specify per hour, week or month) - Employer 2
Reason for leaving - Employer 2*
Duties - Employer 2*
Employer 3:
Name - Employer 3*
Address - Employer 3*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employed From - Employer 3*

MonthDayYear
Date
Employed To - Employer 3*

MonthDayYear
Date
Hours Per week - Employer 3*
Position Title - Employer 3*
Supervisor - Employer 3*

First NameLast Name
May we contact your supervisor? - Employer 3*

YesNo
Supervisor Phone Number - Employer 3*
Please enter a valid phone number.Format: (000) 000-0000.
Number and types of employees you supervised: - Employer 3*
Last salary (specify per hour, week or month) - Employer 3
Reason for leaving - Employer 3*
Duties - Employer 3*
CONTACTS / REFERENCES

Please list three professional references of persons not related to you and who know your qualifications:
Reference 1:
Name - Reference 1*

First NameLast Name
Address - Reference 1

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number - Reference 1*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship - Reference 1*
Reference 2:
Name - Reference 2*

First NameLast Name
Address - Reference 2

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number - Reference 2*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship - Reference 2*
Reference 3:
Name - Reference 3*

First NameLast Name
Address - Reference 3

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number - Reference 3*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship - Reference 3*
May we contact your references?*

YesNo
Have you ever been convicted of an offense in a court of law? (Felonies, Misdemeanors, Etc.)*

YesNo
If "yes" please give dates, details and penalties for each occurrence below. Do not include minor traffic violations. An answer of "yes" does not constitute an automatic bar to employment.*
OPTIONAL - attach resume and/or cover letter

Cancelof
Certification

Application requires current date and original signature to process
Check box to acknowledge the following statement:*

I hereby certify that all entries on this form are true and complete, and I agree and understand that any falsification of information herein, regardless of time of discovery, may cause forfeiture on my part of any employment with Superior Health Support Systems (SHSS). I understand that all information on this application is subject to verification and I consent to criminal history background checks. I also consent that Superior Health Support Systems may contact references, former employers and educational institutions listed regarding this application. I further authorize SHSS to rely upon and use, as it sees fit, any information received from such contacts. Information contained on this application may be disseminated to other agencies, nongovernmental organizations or systems on a need-to-know basis for good cause as determined by the agency head or designee.
Applicant Signature*
Date Completed*

MonthDayYear
Date
Position you are applying for:
Should be Empty:

Application for Employment

EDUCATION

EXPERIENCE

Employer 1:

Employer 2:

Employer 3:

CONTACTS / REFERENCES

Reference 1:

Reference 2:

Reference 3:

Certification