Maple Lawn Medical Care Facility
50 Sanderson Lane
Coldwater, MI 49036
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
Nursing State Certified
Nursing Certification Number
Date of Application Dec 8, 2023
How did you learn about us?
If Other, please specify?
Last Name
First Name
Maiden Name
Middle Name
Address
City, State Zip , 
Telephone Number(s)
Email
Best time to contact you at home is
If you are under 18 years of age, can you provide required proof of your eligibility to work?
Have you ever filed an application with us before?
If Yes, give date
Have you ever been employed with us before?
If Yes, give date
Do any of your friends or relatives work here?
Are you currently employed?
May we contact current employer?
Have you ever been arrested?
If Yes, give date
Charge
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.
Date available for work
What is your desired salary range?
Are you seeking
Desired shift
Number of desired hours per week
Education
Name of School
School Address
Diploma or degree earned
Describe any specialized training, job-related skills, volunteer activities, and any additional information you feel may be helpful to us in considering your application.
Employment Experience
Start with your present or last job. Include any job-related military service assignments
1. Employer
Address
Telephone Number(s)
Job Title
Supervisor
Date Employed
From To
Hourly Rate/Salary
Start End
Reason for Leaving
Work Performed
 
2. Employer
Address
Telephone Number(s)
Job Title
Supervisor
Date Employed
From To
Hourly Rate/Salary
Start End
Reason for Leaving
Work Performed
 
3. Employer
Address
Telephone Number(s)
Job Title
Supervisor
Date Employed
From To
Hourly Rate/Salary
Start End
Reason for Leaving
Work Performed
 
4. Employer
Address
Telephone Number(s)
Job Title
Supervisor
Date Employed
From To
Hourly Rate/Salary
Start End
Reason for Leaving
Work Performed
References
Name
Address
Phone Number
 
Name
Address
Phone Number
 
Name
Address
Phone Number
 
Name
Address
Phone Number
Additional Files (Resume, References, ect)


Electronic Signature (type your name here)Date
 
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.