Human Resources Department

Application for Employment

Brightmoor Nursing Center is an equal opportunity employer and does not discriminate against applicants because of sex, race, religion, genetic information, age, veteran status, national origin, and/or disability. Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department. The use of this form does not mean there are positions open and does not obligate us in any way.

Position(s) applied for: Date of Application: / /

First Name: Middle Name: Last Name:

Social Security Number:

Address City State Zip Code

Home Phone Number: Cell Phone Number: Email Address:

How did you hear about us?

Answering YES to the following questions does not constitute an automatic bar to employment, factors such as date of the offense, seriousness and nature of the violation, rehabilitation, and position applied for will be considered.

Have you ever been employed here before? If yes, give dates and positions:

Have you ever been employed at any other Brightmoor facility? YES NO

If yes, please list the name of the Brightmoor facility, and dates employed:

Have you ever plead guilty or no contest to or been convicted of a crime? YES NO

Are you eligible for employment in this country? YES NO

Date available for work: / / What is your desired payrate?

Type of employment desired: Full Time Part Time PRN Temporary Seasonal Educational Co-Op

Driver’s license number if driving may be required in position for which you are applying: State:

Starting with your most recent employer, provide the following information.

Employer Telephone Number Dates Employed

Street Address City/State/Zip Starting Pay/Ending Pay

Starting Job Title/Ending Job Title Immediate Supervisor Name and Number May we contact for reference?

Please summarize type of work performed and job responsibilities.

Why did you leave?

What were the things you liked most about your position?

What were the things you liked least about your position?

Employer Telephone Number Dates Employed

Street Address City/State/Zip Starting Pay/Ending Pay

Starting Job Title/Ending Job Title Immediate Supervisor Name and Number May we contact for reference?

Please summarize type of work performed and job responsibilities.

Why did you leave?

What were the things you liked most about your position?

What were the things you liked least about your position?

Employer Telephone Number Dates Employed

Street Address City/State/Zip Starting Pay/Ending Pay

Starting Job Title/Ending Job Title Immediate Supervisor Name and Number May we contact for reference?

Please summarize type of work performed and job responsibilities.

Why did you leave?

What were the things you liked most about your position?

What were the things you liked least about your position?

Please summarize and special skills, training, certifications, and licenses that may assist you in performing the position for which you are applying.

Starting with you most recent school attended, please provide all education completion history.

School Attended GED-Diploma-Certificate-License

Please list name and telephone number of three business/work references who are not related to you and are not previous employers. If not applicable, please list three school or personal references who are not related to you.

Name Phone Number Relationship

I certify that all information I have provided in order to apply for and secure work with this employer is true, complete and correct. I understand this application is not intended to and does not create a contract or offer of employment and state that, if hired, employment with the company would be on an at-will basis and could be terminated at the will of either party. I expressly authorize, without reservation, the employer, it’s representatives, employees, or agents to contact and obtain information from all references (personal and professional) employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview. I hereby waive all rights and claims I may have regarding the employer, its agents, employees or representatives, for seeking, gathering and using truthful and non-defamatory information, in a lawful manner, in the employment process and all other persons, corporations or organizations for furnishing such information about me. I understand that this employer does not lawfully discriminate in employment and no question on this application is used for the purpose of limiting or eliminating any applicant from consideration for employment on any basis prohibited by applicable local, state or federal law. I understand that this application is only valid for 30 days. If I wish to still pursue employment, it will be necessary to reapply and fill out a new application. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time with or without cause, with or without prior notice except as required by law. I also understand that if I am hired, I will be required to provide proof of identity and legal authorization to work in the United States and that federal immigration laws require me to complete an I-9 form in this regard. I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be enough cause to elimination from further consideration for employment, or may be the result of immediate discharge from the employer’s service, whenever it is discovered. By signing below, I certify that I have read, fully understand, and accept all terms of the foregoing Applicant Statement.

Signature of Applicant Date

Brightmoor Nursing Center Interview Questions

Applicant Name: Date:

1.What makes you a great asset to our team?

2.What do you look for in an employer and your team?

3.How did you hear about Brightmoor and what have you heard?

4.If applicable, describe a difficult work experience regarding a patient or family member and how you handled it.

5.Describe a difficult work scenario regarding a coworker or supervisor and how you handled it.

6.Where do you see yourself in five years?

For Brightmoor Management

Should an offer be extended? Yes or No

If no, Interviewer Reason:

Offer Amount: Circle one: Hourly or Annual Salary

Position: Shift:

Status: Full time or PRN

Date Available to start:

Interviewer Signature: Date:

Additional Comments:

Reference Check Form

To be completed by Management

Applicant Name:

Date of Reference Check:

Reference Check Completed by:

Reference Check #1:

Place of Employment:

Person Verifying employment:

Position Held: Dates Employed: to

Eligible for Rehire:

Reference Check #2:

Place of Employment:

Person Verifying employment:

Position Held: Dates Employed: to

Eligible for Rehire:

Employment History

Skills and Qualifications

Education

References

Applicant Statement- Do not sign until you have read the statement below.

Contact this candidate