FRANKFORT PINES

FRANKFORT PINES

119 Airport Rd Frankfort, MI 49635
Phone: 231-352-1000 | Fax: 231-352-8044

We are an equal opportunity employer. It is the policy of this organization not to discriminate on the basis of race, sex, religion, national origin, marital status, age, weight, height, color or mental or physical handicap, in the hiring, promotion, payment or discipline of employees.
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Do you currently have a valid driver's license?

YesNo
Email address
example@example.com
Are you 18 years of age or older?

YesNo
Position(s) applied for
Have you received a job description for the position (s) applied for?

YesNo
Can you perform the duties of the job in which you wish to be employed, with or without accommodation?

YESNO
We are licensed to provide care 24 hours a day, 7 days a week, 52 weeks a year. Working overtime hours is expected for continued employment. Are you able to meet this requirement?

YesNo
Have you ever been convicted of a crime? If yes, please explain

YesNo
Explain
Are there any felony charges pending against you? Yes No If yes, please explain

YesNo
Explain
Have you ever been determined by a federal, state or local governmental agency to have committed abuse or neglect?

YesNo
If yes, when, where, and nature of the case
Are you on court-supervised probation or parole? Yes No If yes, please explain

YesNo
Explain
Have you ever been the subject of a Department of Commerce adult foster care licensing investigation?

YesNo
Explain
Have you ever personally been investigated by the Department of Commerce Adult Protective Service Unit, Department of Mental Health Recipient Rights Office, a Community Mental Health Recipient Rights Office or other recipient rights office?

YesNo
Explain
Have you ever been the subject of a federal, state or local agency investigation concerning client welfare?

YesNo
Explain
Have you ever been employed by this organization before?

YesNo
If yes, provide the dates employed and indicate if employed under a different name
In case of emergency, whom should we contact?
Name
Phone
Relationship
EDUCATION
High School Attended
Type a question

GraduateGED
City/State
Additional education
Work History

	Employer Name, Address and Phone Number	Dates Employed	Reason for Leaving
Job 1
Job 2
Job 3

PERSONAL REFERENCES

	Name & Address	Relationship	Phone
Job 1
Job 2
Job 3

EMPLOYMENT REFERENCES

	Name & Address	Phone
Job 1
Job 2
Job 3

For security purposes, we use an audio/video surveillance system to monitor our building. It may be recording at any time. A criminal background check and drug test may be required as a condition of employment.

I have read and understand the above questions and policies. I agree to the terms listed and declare that my answers are true to the best of my knowledge:
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

FRANKFORT PINES

EDUCATION

Work History

PERSONAL REFERENCES

EMPLOYMENT REFERENCES