Maple Lawn Medical Care Facility
50 Sanderson Lane
Coldwater, MI 49036
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Application for Employment |
We consider applicants for all positions
without regard to race, color, religion,
creed, gender, nation origin, age,
disability, marital or veteran status,
or any other legally protected status. |
Position(s) Applied For |
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Nursing State Certified |
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Nursing Certification Number |
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Date of Application |
Nov 7, 2024 |
How did you learn about us? |
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If Other, please specify? |
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Last Name |
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First Name |
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Maiden Name |
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Middle Name |
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Address |
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City, State Zip |
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Telephone Number(s) |
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Email |
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Best time to contact you at home is |
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If you are under 18 years of age, can you
provide required proof of your eligibility to
work? |
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Have you ever filed an application with us
before? |
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If Yes, give date |
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Have you ever been employed with us before? |
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If Yes, give date |
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Do any of your friends or relatives work
here? |
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Are you currently employed? |
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May we contact current employer? |
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Have you ever been arrested? |
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If Yes, give date |
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Charge |
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Are you prevented from lawfully becoming
employed in this country because of Visa or
Immigration Status?Proof of citizenship or immigration
status will be required upon employment. |
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Date available for work |
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What is your desired salary range? |
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Are you seeking |
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Desired shift |
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Number of desired hours per week |
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Education |
Name of School |
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School Address |
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Diploma or degree earned |
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Describe any specialized training,
job-related skills, volunteer activities,
and any additional information you feel may
be helpful to us in considering your
application. |
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Employment Experience |
Start with your present or last job. Include
any job-related military service assignments |
1. Employer |
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Address |
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Telephone Number(s) |
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Job Title |
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Supervisor |
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Date Employed |
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Hourly Rate/Salary |
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Reason for Leaving |
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Work Performed |
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2. Employer |
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Address |
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Telephone Number(s) |
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Job Title |
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Supervisor |
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Date Employed |
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Hourly Rate/Salary |
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Reason for Leaving |
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Work Performed |
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3. Employer |
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Address |
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Telephone Number(s) |
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Job Title |
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Supervisor |
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Date Employed |
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Hourly Rate/Salary |
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Reason for Leaving |
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Work Performed |
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4. Employer |
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Address |
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Telephone Number(s) |
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Job Title |
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Supervisor |
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Date Employed |
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Hourly Rate/Salary |
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Reason for Leaving |
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Work Performed |
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References |
Name |
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Address |
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Phone Number |
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Name |
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Address |
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Phone Number |
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Name |
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Address |
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Phone Number |
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Name |
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Address |
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Phone Number |
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Additional Files (Resume, References, ect) |
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Electronic Signature (type your name here)Date |
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I certify that answers given herein are
true and complete.
I authorize investigation of all
statements contained in this application
for employment as may be necessary in
arriving at an employment decision.
I hereby understand and acknowledge
that, unless otherwise defined by
applicable law, any employment
relationship with this organization is
of an "at will" nature, which means that
the Employee may resign at any time and
the Employer may discharge Employee at
any time with or without cause. It is
further understood that this "at will"
employment relationship may not be
changed by any written document or by
conduct unless such change is
specifically acknowledged in writing by
an authorized executive of this
organization.
In the event of employment, I understand
that false or misleading information
given in my application or interview(s)
may result in discharge. I understand,
also, that I am required to abide by all
rules and regulations of the employer.
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