Employment Application

Date*

Date

Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

E-mail*

example@example.com

Are you 18 years or older?*

YesNo

Do you have transportation?*

YesNo

Some positions may require driving. Do you have a valid, unrestricted driver's license and insurance?*

YesNo

Are proceedings pending to suspend or revoke your driver's license?*

YesNo

If yes, please explain

Date Available To Start:*

Date

Social Security No.:

Desired Salary/Hourly Rate:*

How far (distance/time) are you willing to travel from home for work?*

0 – 5 miles / 5 – 15 minutes5 – 10 miles / 10 – 25 minutes10 – 15 miles / 20 – 35 minutes15 – 20 miles / 30 – 45 minutes20 or more miles / 40+ minutes

Position Applied for:*

Location Applied for (if known):*

Do you have a Professional License or Certification?*

List State(s) where your Professional License and/or Certification is registered.

Do you have a CURRENT BLS, CPR, or First Aid certification? (Check all that apply)*

BLSCPRFirst AidNone of the above

I will provide a copy of my current BLS, CPR, or First Aid certification(s) below.

YesNo

Are you able to perform the essential job functions associated with the job for which you have applied for without accommodation for a protected disability or religious practice? Note: Timeliness and good attendance are essential functions for all jobs.*

YesNo

Is there an accommodation that would permit you to perform the function?

Yes - If yes, please list belowNo

Please state what the accommodation may be

Are you legally authorized to work in the U.S for any employer? *Note: Proof of identity and eligibility will be required upon employment.*

YesNo

If no, are you authorized to work in the U.S.?

YesNo

Have you ever worked for this company?*

YesNo

If yes, when did you work for this company?

Have you ever applied to this company?*

YesNo

How did you hear about this employment opportunity?*

Employee Referral Name

First NameLast Name

Please specify other source

Have you ever been convicted (including a plea of guilty or no contest) of a crime (misdemeanor or felony) by a court, including a military court?*

YesNo

Please list conviction(s) and date(s)

Are there misdemeanor or felony charges pending against you? *

YesNo

Please list charge(s) and date(s)

Have you ever been excluded, suspended, debarred, or otherwise declared ineligible to participate in any government funded programs (including but not limited to Medicare or Medicaid)*

YesNo

If yes, please explain

Are you currently under a legal agreement such as a non-compete agreement or a settlement agreement, which might prevent you from working at for another company or from rendering services to specific Grosse Pointe Home Care clients?*

YesNo

High School / GED: Name
Address
Have you received a high school diploma or its equivalent? Yes No
Diploma:

College: Name
Address
Did you graduate? Yes No
Degree:

Other: Name
Address
Did you graduate? Yes No
Degree/Certificate:

Full Name:First Name*   Last Name* Position/Title   *
Company:   *
Address:   Street Address* City* State*   Zip*
Phone    Phone Number*

Full Name:First Name   Last Name Position/Title   Type a label
Company:   Type a label
Address:   Street Address City State   Zip
Phone    Phone Number

Company:   Name   Phone:   Phone Number
Supervisor:   First Name   Last Name
Address:   Street Address   City State   Zip
Job Title:
Starting Salary $      Ending Salary $
Responsibilities:
From:   Date   To:   Date
Reason for Leaving:
May we contact your previous supervisor for a reference?   Yes   No

Branch From:Date   To:   Date
Rank at Discharge:
Type of Discharge:   Type a label
If other than honorable, explain:   Type a label

Resume

You may submit your resume here.

Certification(s) for BLS, CPR, or First Aid

You may submit your resume here.

Authorization

*Please note your application will not complete until singed and submitted.

I certify that the facts, answers, and information given by me in this application, my resume, and in any other materials I have submitted are true, accurate, and complete. I understand that, if employed, my employment may be terminated immediately if Grosse Pointe Home Care discovers that I have withheld or omitted any information, or provided false, inaccurate, or misleading information in this application, my resume, or any other materials submitted, or in any other document or form executed by me at any time during my employment.

I authorize Grosse Pointe Home Care to verify the information provided and to investigate my background as deemed necessary. I authorize former employers, personal references, or other agencies, institutions, or persons (collectively referred to as "person") to provide Grosse Pointe Home Care any information they have regarding me without receiving written notice from me. I hereby release and agree to hold harmless from liability and covenant not to sue any person providing information pursuant to this authorization. I hereby waive written notice by my present and/or former employers whenever a disciplinary report, letter, reprimand or other action regarding me is divulged to Grosse Pointe Home Care by present or former employers. I understand that employment arising out of this application is contingent upon the results of the investigation. I also understand that Grosse Pointe Home Care may condition an offer of employment upon my passing a physical examination, including a drug test, prior to employment.

I agree to immediately notify Human Resources if I should be arrested for a felony or convicted of a crime, including a plea of no contest, during my tenure at Grosse Pointe Home Care.

In consideration of my employment, I agree and understand that my employment and compensation can be terminated with or without notice and with or without cause either at my option or at the option of Grosse Pointe Home Care, it being mutually understood and agreed that my relationship with Grosse Pointe Home Care is one of employment at-will, and no representative of the company has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. Any agreement altering the at-will nature of the employment relationship must be in writing and signed by me and an authorized company representative. I also understand and agree that any fringe benefits I receive as a result of my employment may be modified by Grosse Pointe Home Care and do not vest by reason of my employment or continued employment, and that fringe benefits are subject to change by Grosse Pointe Home Care with or without notice to me.

I agree not to commence any action or lawsuit including, but not limited to, claims arising under state or federal civil rights statutes related to my application for employment or employment against Grosse Pointe Home Care or its employees, more than one hundred eighty (180) days after the occurrence of the facts giving rise to the claim, or more than one hundred eighty (180) days after the date of my termination of employment, whichever is earlier, and to waive any longer statute of limitations to the contrary. In the event that the statute of limitations applicable to any such claim is less than one hundred eighty (180) days, I agree that the shorter statute of limitations shall apply.

I understand that Michigan law requires employers to make accommodations to disabled applicants and employees where the accommodation does not impose an undue hardship on the employer. I further understand that disabled employees and applicants must request an accommodation of their disability by notifying Grosse Pointe Home Care in writing of the need for accommodation within one hundred eighty two (182) days of the date the individual knows or should know that an accommodation is needed. Failure to properly notify Grosse Pointe Home Care will preclude any claim that Grosse Pointe Home Care to accommodate the disability under state law.

Please read the above carefully before signing the employment application. Your signature, whether handwritten or electronic, indicates that you have read, understand, and agree to the above statements and conditions of employment. Your signature also indicates that you understand and agree that, if hired, you will be subject to all rules, regulations, policies, and practices of Grosse Pointe Home Care in force at the time of your employment or that may later be adopted.

I certify that I am the person named on this application, and I agree to all terms and conditions contained in this application as well as associated forms and authorizations.

Signature: (If using your mouse to sign your name, you will need to hold down left click while signing your name.) *

Signature*

Date*

Date

Hour MinutesAM/PM Option

Grosse Pointe Home Care Employment Application

Education

References

Previous Employment

Military Service

Authorization