Benjamin's Hope Sidekick Application

Section I: Equal Employment Opportunity Employer

Benjamin’s Hope is 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, disability or veteran status in the hiring, promotion, compensation or discipline of employees. If you are a person with a disability, you many 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: Applicant's Personal Information
First Name*
Middle Name
Last Name*
Address Line 1
Address Line 2
City
State
Zip
Preferred Phone
Email
How did you hear about Benjamin's Hope?
Why do you want to work at Benjamin's Hope?
Please describe any experience you have working with people with developmental differences.
What else should we know about you?

Section IV: Education
High School
City:
State

Street Address

Street Address Line 2

City

Zip Code
College:
City:
State

Street Address

Street Address Line 2

City

Zip Code
Did you graduate?

YesNo
If yes, what degree did you obtain?
Trade School:
City:
State

Street Address

Street Address Line 2

City

Zip Code
Did you graduate?

YesNo
If yes, what certificate did you obtain?
Professional / Graduate School
City:
State

Street Address

Street Address Line 2

City

Zip Code
Did you graduate?

YesNo
If yes, what degree or certificate did you obtain?

Section V: Employment History

Please start with your current or most recent employer.
Current or Most Recent Employer
Company Name
Phone:
Position:
Start Date:
End Date:
Name of Supervisor:
Reason for Leaving:
May we contact your current supervisor or manager?

YesNo
If no, why?
Employer #2
Company Name
Phone:
Position:
Start Date:
End Date:
Name of Supervisor:
Reason for Leaving:
Employer #3
Company Name
Phone:
Position:
Start Date:
End Date:
Name of Supervisor:
Reason for Leaving:
Employer #4
Company Name
Phone:
Position:
Start Date:
End Date:
Name of Supervisor:
Reason for Leaving:
Have any of your previous employers served persons funded through a community mental health (CMH) entity?

YesNoNot sure
If yes, which CMH entities were involved?
Do you understand that we 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 VI: References

Give the names of two (2) personal references who Benjamin's Hope may contact for a reference check prior to your employment. Please include people who are not related to you, whom you have known at least one (1) year. We will send your references an email when completing reference checks. Please make sure to include an email address.
Personal Reference #1
Name:
Phone:
Email (needed for reference checks):
Relationship:
Personal Reference #2
Name:
Phone:
Email (needed for reference checks):
Relationship:
Give the names of two (2) professional references from supervisors, managers, administrators or executive directors for whom you have worked. By including this information, you give Benjamin's Hope permission to contact these individuals as part of our reference check process prior to your employment. You may include volunteer or ministry work.
Professional Reference #1
Name:
Phone:
Email (needed for reference checks):
Relationship:
Professional Reference #2
Name:
Phone:
Email (needed for reference checks):
Relationship:

Section VII: Professional Licenses, Certifications and Credentials

Do you have any of the following licenses or certifications?
Certified Nurse Aid

YesNo
Nursing License

YesNo
Direct Support Professional

YesNo
Do you have any other job-related licenses, certifications or credentials (CPR, First Aid, Lifeguard, EMT)?

YesNo
If yes, please provide details:

Section VIII: Consent
I certify that all 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 interview or pre-employment process are grounds for disqualification for consideration for employment or termination of employment if the discovery is made after employment begins.
Please indicate your agreement with the above statement by typing your full name:
Date:
I hereby give you my permission to contact the above employers, references, and educational, licensing, credentialing and certification institutions to verify the items I listed above. I hereby release Benjamin’s Hope and the above referenced organizations, reference persons and employers from all claims, liability and damages that may result from furnishing the information to you. I consent to releasing any information relating to my job performance which is documented in my personnel file. In the event that a prior employer or other organization is obligated to provide any written notice to me regarding the disclosure of information to Benjamin’s Hope, I hereby waive that 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 or 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 Benjamin’s Hope, 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 the 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 employers, and hereby release any prior employers from all claims, liability and damages that may result from furnishing the information to you.
Please indicate your agreement with the above statement by typing your full name:
Date:
Section IX: At-Will Status
In consideration of my employment, I agree to conform to the policies, rules and regulations of Benjamin’s Hope. I understand and agree that my employment and compensation are for no definite period 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 Benjamin’s Hope or myself.
Please indicate your agreement with the above statement by typing your full name:
Date:
Section X: Prior to Employment
I understand that if offered employment, the offer is dependent upon my satisfactorily passing a physical examination and associated laboratory test, which may include drug and alcohol screening, a TB test, and background check.

I also understand that prior to employment I will need to complete necessary training that is required by Benjamin’s Hope.
Please indicate your agreement with the above statement by typing your full name:
Date:
Should be Empty:

Section I: Equal Employment Opportunity Employer

Section II: Applicant's Personal Information

Section II: Applicant's Personal Information Continued

Section II: Applicant's Personal Information Continued

Section III: Availability and Interest in Work

Section IV: Education

Section V: Employment History

Section VI: References

Section VII: Professional Licenses, Certifications and Credentials

Section VIII: Consent

Section IX: At-Will Status

Section X: Prior to Employment