UPON HIRING HAVE WITH YOU
Valid MI Drivers License
or MI ID card, and
Original, Signed, Social
Security Card

PRE EMPLOYMENT APPLICATION

Westland Convalescent & 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.
Westland Convalescent Center
Today's Date: Month/Day/Year
NAME   Last, First, Middle Social Security Number
EMAIL
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 and 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 a citizen of the U.S.A.? Yes      No (Employment of a non-U.S.A. citizen is dependent upon appropriate visa status)
List relatives & friends now employed by or a patient at WCC
Name    Name
Name    Name


Job Interest
Positions desired
or area of interest 		1. Shift Desired  
2. Full Time   Part Time
May we contact your present employer? Yes      No
How soon will you be available?
Have you previously applied at WCC? If so, when?
Name used (if yes to previous)
What starting salary range do you consider appropriate? $  to  $ per hour


Education
Are you currently registered and attending classes? Yes  No
If so, where? 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

Type of School Name and Location
of School		 Years
From - To		 Field of
Specialization		 Degree Year
Graduated		 Average Grade
High School to
Undergraduate
College		 to
Graduate or
Professional		 to
Other to


Address
Current Mailing Address
Number and Street Area Code Telephone
City    State Zip Code Country


Permanent Address (if different than above)
Number and Street Area Code Telephone
City    State Zip Code Country


In case of an emergency call:
Name Relationship   Name Relationship
Address Address
Telephone Number Telephone Number

Where did you hear about our facility?

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 Years of experience

Special Skills
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
If you have performed military service,
give 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 our without accommodation to perform the 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 you are seeking, such as heavy lifting, pushing, pulling, etc.? Yes   No
Please list any additional details necessary to complete or clarify your application

Miscellaneous Information
LIST PREVIOUS EMPLOYERS - MOST RECENT FIRST
Dates
Mo. - Yr.		 Employer NOTE: please state if you were employed under a different name. List most recent employment first, include all positions with each employer. This section should be completed even if you send a resume.
Responsibilities
From
 Name
 Title of Position
To
 Address (city and state)
 Duties (including supervision)
Final Salary
 Type of Business or Institution
Supervisor's Name
Reason for Leaving
From
 Name
 Title of Position
To
 Address (city and state)
 Duties (including supervision)
Final Salary
 Type of Business or Institution
Supervisor's Name
Reason for Leaving
From
 Name
 Title of Position
To
 Address (city and state)
 Duties (including supervision)
Final Salary
 Type of Business or Institution
Supervisor's Name
Reason for Leaving
From
 Name
 Title of Position
To
 Address (city and state)
 Duties (including supervision)
Final Salary
 Type of Business or Institution
Supervisor's Name
Reason for Leaving
From
 Name
 Title of Position
To
 Address (city and state)
 Duties (including supervision)
Final Salary
 Type of Business or Institution
Supervisor's Name
Reason for Leaving


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 birthday within my probationary period as a condition of employment.

I understand the information on this application is subject to check and verification by WCC 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 prove me with written notification of such disclosure.

I hereby grant permission to WCC 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, WCC 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 WCC 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 WCC 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 WCC and I agree that I shall be bound by the rules, policies and regulation of WCC 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.

Digital Signature of Applicant


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