Application for Westland Nursing & Rehab Center

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Employment Application

36137 West Warren
Westland, MI 48185
Phone: (734) 728-6100
Fax: (734) 728-9741

WHEN APPLYING, PLEASE BRING: Valid Michigan drivers license or Michigan ID card, original, signed, social security card and proof of certification or professional license. PRE EMPLOYMENT APPLICATION Westland Nursing & Rehab Center is a DRUG FREE WORKPLACE. All applicants will be drug tested to detect improper self medication or the presence of alcohol or illegal drugs. *Required
*Please Select Department Applying for:
Today's Date: Month/Day/Year		Social Security Number:
*Name: Last, First, Middle		*E-Mail:
Give name as you wish it to appear for official purposes. Abbreviations of a given name or initials may be used. The name including all spaces an letters must be 30 or less.
May we call you at work?	Yes No
Are you 18 years of age or older?	Yes No
Are you authorized to work in the United States?	Yes No
(Employment of non-U.S.A. citizen is dependent upon appropriate visa status) List relatives & friends now employed by or a patient at WCRC
Name:		Name:
Name:		Name:

Job Interest
Position Desired:	1.	2.
Full Time	PartTime
Shift Desired:
May we contact your present employer?	Yes No
How soon will you be available?
Have you previously applied at WCRC? If so, when?
Name used (if yes to previous):
What starting salary range do you consider appropriate?	$ to $ pr hr

Education
Are you currently registered and attending classes? Yes No
Hours registered:
If you have completed college degrees within the last five years please send us a copy of your transcript.
If degree/certificate is expected, state the year and degree title Year: Degree:
School	Name	Years From - To	Field	Degree	Year Graduated	GPA
High School		to
Undergraduate College		to
Graduate or Professional		to
Other		to

Current Address
Street:	* Telephone:
City:	State:	Zip:	Country:
Permanent Address (if different than above)
Street:	Telephone:
City:	State:	Zip:	Country:

Emergency Contact
Name:		Relationship:
Address:		Telephone:
Name:		Relationship:
Address:		Telephone:

Honors and Awards

Past and Present Service to government agencies, civic activities, or honorary societies

Professional honors, licenses, etc.

Special Skills
If applicable, please indicate any trade, office, technical skill or other skills or interests and abilities possessed by you(i.e. typing, shorthand, office machines, keypunching, programming, laboratory skills)
Skill	Length and kind of training




Where Obtained	Years of experience

Languages
List foreign language in which you have some proficiency and check proper columns.
	Reading	Speaking	Understanding	Writing
	Good \| Fair	Good \| Fair	Good \| Fair	Good \| Fair

Military
Military Service Period:	to
Branch of Service:
Last Rank or Rating:
Type of Discharge:

Miscellaneous Information
Have you ever been convicted of anything, other than a minor traffic violation?	Yes No
Are any current felony charges outstanding?	Yes No
If either of the previous questions was answered "yes", please give dates, places, charges, disposition and all other pertinent facts relation to any convictions or outstanding felony charges.
Do you have the ability, with or without accommodation to perform the essential functions of the job you are seeking, which may include, heavy lifting, pushing, pulling, etc.?	Yes No
Are you able to demonstrate your ability, with or without accommodation, to perform the functions of the job?	Yes No
Do you have any outside commitments or conflicts that might affect your employment with the facility? Yes No
I understand that providing information not specifically asked for in this application or failing to accurately inclose information specifically asked, will disqualify my application from being considered for employment. (Type Initials)

Employment History
List Previous Employers-Most Recent First
Dates Mo.-Yr.	Employer	Responsibilities
From:	Name:	Title of Position:
To:	Address (city and state)	Type of Business or Institution:
Final Salary	Supervisor's Name:	Reason for Leaving:
Duties (including supervision)

From:	Name:	Title of Position:
To:	Address (city and state)	Type of Business or Institution:
Final Salary	Supervisor's Name:	Reason for Leaving:
Duties (including supervision)

From:	Name:	Title of Position:
To:	Address (city and state)	Type of Business or Institution:
Final Salary	Supervisor's Name:	Reason for Leaving:
Duties (including supervision)

From:	Name:	Title of Position:
To:	Address (city and state)	Type of Business or Institution:
Final Salary	Supervisor's Name:	Reason for Leaving:
Duties (including supervision)

PLEASE READ THE FOLLOWING CAREFULLY BEFORE YOU TRANSMIT YOUR APPLICATION

I understand that I might have to work rotating shifts and am able to do so.

I understand that I may be fingerprinted and must produce evidence of my birthdate within my probationary period as a condition of employment.

I understand the information on this application is subject to check and verification by WCRC and that my previous and present employers may be asked for information relative to my employment record with them.

I understand that my previous history may include a record of disciplinary action, and hereby release previous employers from any obligation to provide me with written notification of such disclosure.

I hereby grant permission to WCRC to contact those employers and further, I hereby authorize my former employers to give any information as to my character and employment record with them.

I hereby release from all liability and damages, WCRC and those individuals or companies who provide such information.

I understand that any omission or misrepresentation of fact in this application may result in refusal of or immediate separation from employment.

I understand that my employment would be contingent on my satisfactorily passing a physical examination required by the corporation.

I hereby authorize WCRC to deduct from each and every pay period any amounts necessary to offest and damages caused by me, or the value of property or money entrusted to me or owed by me to WCRC during the course of my employment.

I understand that either party may terminate the employment relationship, with or without cause, at any time, for any reason.

If hired, I understand I will serve at the will of WCRC and I agree that I shall be bound by the rules, policies and regulation of WCRC as they are from time to time changed with or without notice to me.

I HEREBY CERTIFY THAT THE INFORMATION GIVEN BY ME IN THIS APPLICATION IS TRUE IN ALL ASPECTS , AND I UNDERSTAND THAT IF I AM EMPLOYED AND IT IS FOUND TO BE FALSE, THAT I WILL BE SUBJECT TO DISMISSAL.

You are subject to a pre-employment drug screen. Your employment may start before results have been received. Positive testing will result in discharge.

I agree that any claim or lawsuit relating to my service with the employer or any of its subsidiaries must be filed no more than six (6) months after date of employment action that is subject of the claim or lawsuit. I wave any statute of limitations to the comtrary.

Digital Signature of Applicant

NOTE: Please click the submit button only once. It may take several seconds to transmit your application depending on your Internet connection type.