NAME :
SS# :
ADDRESS :
CITY :
STATE :
ZIP CODE:
PHONE # :
CELL PHONE # :
EMAIL :
EMERGENCY CONTACT :
PHONE # :
Position(s) applied for :
Date available to start :
Salary desired :
Are you seeking :
Full-time
Part-time
Temporary Employment
Are there any days or hours you would be unable or unwilling to work?
Yes
No
If yes, please specify those days or hours :
Have you received a job description for the position(s) for which you are applying?
Yes
No
If the position you applied for requires driving, do you currently have a valid drivers license?
Yes
No
Drivers license # :
State Issued by :
Do you have any tickets on your driving record for moving violations?
Yes
No
If yes, state date(s) and violation(s) :
Are you 18 years of age or older?
Yes
No
Can you perform the duties of the job in which you wish to be employed, with or without reasonable accommodation?
Yes
No
Have you ever been convicted of a crime?
Yes
No
If yes, was this crime a felony?
Yes
No
Are there any criminal charges pending against you?
Yes
No
If yes, please explain
:
Are you on a court-supervised probation or parole?
Yes
No
If yes, please explain :
(Note: Applicants SS# may be disclosed to a third party that will conduct a background check, my initials in the box denote my agreement for such use.)
Do you have a Professional license (i.e. Nurse, Social Worker, etc.)?
Yes
No
License No. :
State Issued :
Expires :
If yes, has your professional license ever been suspended or revoked?
Yes
No
If yes, please explain :
Have you ever been involuntarily terminated?
Yes
No
If yes, please explain :
Have you ever been employed by this organization before?
Yes
No
If yes, give dates and facility employed :
Do you know any employees of this organization?
Yes
No
If yes, please list all names :
Are you related to any employee of this organization?
Yes
No
If yes, please list all relatives names :
If you worked in any of your previous positions under another name, please give that name :
Have you ever been administratively determined by a federal, state or local governmental agency to have committed abuse or neglect?
Yes
No
If yes, please explain when, where, and nature of the case:
List any special skills and/or training that would apply to this position, and briefly state your reasons for wanting this position :
Employment History
List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and supply business references.
Name of employer:
Nature of business:
Address:
City, State, Zip:
Telephone:
Name and title of last supervisor:
Title:
Duties:
Dates employed:
From:
To:
Pay:
Starting:
Ending:
Reason for leaving:
Name of employer:
Nature of business:
Address:
City, State, Zip:
Telephone:
Name and title of last supervisor:
Title:
Duties:
Dates employed:
From:
To:
Pay:
Starting:
Ending:
Reason for leaving:
Name of employer:
Nature of business:
Address:
City, State, Zip:
Telephone:
Name and title of last supervisor:
Title:
Duties:
Dates employed:
From:
To:
Pay:
Starting:
Ending:
Reason for leaving:
Name of employer:
Nature of business:
Address:
City, State, Zip:
Telephone:
Name and title of last supervisor:
Title:
Duties:
Dates employed:
From:
To:
Pay:
Starting:
Ending:
Reason for leaving:
Education
High School attended :
Graduate
GED
City and State :
Additional Education
School and Address
Degree
Major
Professional References
Name
Address
Phone number
Personal References
Name
Address
Phone number
Release of Information
I hereby give you my permission to contact the above employers, references and educational institutions to verify the items I listed above. I hereby release P.R.S., Inc. (hereinafter Progressive Residential Services, Inc.) and the above referenced organizations, referenced persons and employers for all claims, liability and damages that may result from furnishing the information to you. I expressly and fully waive all written notice from all prior employers. I consent to releasing any information relating to my job performance, which is documented in my personnel file.
I also understand that because of the nature of my job and agency requirements, I hereby consent to the release of this application, or portions of this application, to representatives of the Department of Commerce, Department of Consumer and Industry Services, Department of Health and Human Services, Department of Community Health, and local Community Mental Health agencies, or other governmental or private agencies for all licensing or investigative purposes and to verify information I have listed in this job application. I hereby release PRS, Department of Commerce, Department of Consumer and Industry Services, Department of Health and Human Services, Department of Community Health, and local Community Mental Health agencies, or other governmental 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 my prior employers from all claims, liability and damages that may result from furnishing the information to you.
Name :
Date :
I further understand that any dishonest, false or incomplete answers on this application or in any subsequent interview are grounds for immediate dismissal.
Name :
Date :
This application will be kept current for six months. You need to complete another application to be reconsidered after that date.
Affidavit
I certify that the answers given by me to the foregoing questions and statements are true and correct without any consequential omissions of any kind whatsoever. I understand that any misleading or incorrect statements may render this application void, and if employed, would be cause for my termination. I further agree that the company shall not be liable in any respect if my employment is terminated because of falsity of statements, answers or omissions made by me on this questionnaire. I also authorize the employers, companies, schools or persons named above to give any information regarding my employment, character and qualification, including disciplinary reports, letters of reprimand and other disciplinary actions. I hereby release the employers, companies, schools or persons from all claims and damages that may result from furnishing this information. I understand Employment at Will, and if employed by P.R.S., Inc. I will conform to the rules and regulations of P.R.S., Inc. and that my employment and compensation can be terminated without cause and without notification at any time, at the sole discretion of P.R.S., Inc. I agree to file all employment-related claims within six months and waive any contrary statute of limitations, according to the Michigan Court of Appeals. I agree that no one other than the Administrative Office has any authority to enter into any agreement or contract for any specified period of time, or to make any agreement contrary to the foregoing. I also understand that no person is authorized to enter into any written or verbal employment contracts on behalf of the company without the express written consent of the Administrative Office.
Name :
Date :