Employment Application

PLEASE NOTE: if you accessed this employment application via a generic search on the internet you will not be able to submit it. Instead, please go to the careers section on our website at https://autumnwoods.com/career-opportunities/ and apply directly for a position at the facility of your choice. If you accessed it via our website, please proceed in filling it out. Thank you for your interest in joining our team!

Personal Information

* Required Fields

Name *

Address *

City *

State *

Zip *

Home Phone *

Cell Phone

Work Phone

Social Security Number*

Date Available *

Are you applying for a Physical Therapy or Occupational Therapy position? *
YesNo

Position Desired *

Are you either a U.S. Citizen or an alien authorized to work in the United States? *
YesNo

Are you over 18 years of age? *
YesNo

Are you currently a student? *
YesNo

How did you learn of our organization?

Upload Resume

Upload Cover Letter or Essay (Essay Required for LPN Training Program)

Education

List colleges, trade schools and high schools attended in reverse chronological order.

Name and location of school

Major

Year Completed

Degree/Diploma Earned

Employment History

Have you previously worked for Autumn Woods Health Care Facility? *
YesNo

When?

Previous Employers

List present or most recent employer first.

Employer

Phone

Address

Start Date

End Date

Position

Name of Supervisor

Job Description

Reason for Leaving

Employer

Phone

Address

Start Date

End Date

Starting Hourly Rate

Ending Hourly Rate

Position

Name of Supervisor

Job Description

Reason for Leaving

Employer

Phone

Address

Start Date

End Date

Starting Hourly Rate

Ending Hourly Rate

Position

Name of Supervisor

Job Description

Reason for Leaving

Background Information

Have you ever been convicted of any crime or offense, other than a traffic violation? *
YesNo

State the nature of the crime

No applicant will be excluded from consideration for employment due to prior conviction. Your answer is looked upon as only one of the factors considered in the employment decision and is evaluated in terms of the nature, severity, and date of the conviction.

Have you ever been discharged or asked to resign by any former employer? *
YesNo

If yes, explain in detail

What special skills or qualifications do you possess?

Have you served in the U.S. Armed Forces? *
YesNo

Branch of service

Period of active duty

I hereby represent that each answer to a question herein and on any attachments to the application, and all other information otherwise furnished is true and correct. I further represent that such answers and information constitute a full and complete disclosure of my knowledge with respect to the question or subject to which the answer or information relates. I understand that any incorrect, incomplete or false statements or information furnished by me during the selection process will subject me to disqualification from employment or discharge at any time. I hereby authorize my former employers to give any information regarding my employment with them; and in addition, to furnish any other information they may have concerning me.

I understand this Application for Employment does not constitute an expressed or implied contract of employment and, if hired, I have the right to terminate my employment for any reason at any time. I also understand that the employer reserves the same rights provided such action is not inconsistent with any collective bargaining agreement which may govern the "wages" and "conditions of employment" of the position in which I am employed. I understand the employer reserves the right to unilaterally change or modify "wages" and "conditions of employment" at any time without previous notice, provided such are not subject to collective bargaining.

Employment applications submitted for Certified Nursing Assistant Trainee or Dietary Aide will remain active for future consideration for a period of up to two (2) months from date of submission. Employment applications submitted for all other positions will remain active for a period of up to six (6) months from date of submission.

An offer of employment is subject to satisfactory completion of a medical examination and questionnaire.

Race and Ethnic Identification

Autumn Woods Health Care Facility is subject to certain governmental record keeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, the employer invites employees to voluntarily self-identify their race and ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information or be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

Name

Date

1. Gender
FemaleMale

2. Are you Hispanic or Latino-a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race?

3. Please check
White (not Hispanic or Latino)-a person having origins in any of the original peoples of Europe, the Middle East, or North Africa.Black or African American (not Hispanic or Latino)-a person having origins in any of the Black racial groups of Africa.Native Hawaiian or Other Pacific Islander (not Hispanic or Latino) a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.Asian (not Hispanic or Latino)-a person having origins in any of the original people of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.American Indian or Alaskan Native (not Hispanic or Latino)-a person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.Two or More Races (not Hispanic or Latino)-all persons who identify with more than one of the above five races.

By checking this box, I agree to submit this application electronically and understand that an electronic signature has the same legal status and can be enforced in the same way as a written signature.

Electronic signature *

Date*

Equal Opportunity Employer (EOE)
Michigan and/or federal law prohibits discrimination because of religion, race, color, national origin, age, sex, height, weight or marital status.