Application for Employment

United Nursing Service, Inc. & UNS Home Health Agency, Inc. 2925 Portage St Kalamazoo, MI 49001 1621 44 th St SW Wyoming, MI 49509

We consider applicants for all positions without regard to race, color, religion, creed, gender, national origin, age, disability, marital or veteran status, sexual orientation or any other legally protected status.

Position(s) Applied For: ____________________________ Date of Application: __________ Are you related to anyone who works at United Nursing Service or UNS-HHA? How did you learn about us?

Yes

No

Internet - site? ______________ Employment Agency Walk-In

Job Fair Where? _______________________ Friend Who? Relative Who? Advertisement Which?

___________________ (required) Email Address:_____________________________________ Expected Wage $___________

Your Last Name Address Number Street First Name Apt City Middle Name State Zip

Telephone Number(s)

Social Security Number

Please fill out the whole application. Do not put see resume even if attaching one!

Are you under 18 years of age? Do you have a valid drivers license? Do you have reliable transportation? Are you available to work weekends? Have you ever been employed with us before? If yes, give dates: _________________ 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)

Yes Yes Yes Yes Yes

No No No No No

Yes Yes

No

Are you currently employed? If yes, provide employer

No

Employer address _____________________________________________________________

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Employed since _______________________________________________________________

Have you ever been convicted of a crime? If yes, please explain below.
(Conviction will not necessarily disqualify an applicant from employment)

Yes

No

Misdemeanor

Please list date of conviction and infraction

____________________________________________________________________________

Felony

Please list date of conviction and infraction

____________________________________________________________________________

Do you have any criminal charges currently pending against you? If yes, please explain:

Yes

No

____________________________________________________________________________

Education
Name & Address of School Course of Study Years Completed Diploma Degree

High School College

Trade School

Other
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Employment Experience
Please list all jobs held in the past 10 years starting with your present or last job. Include any job-related military service assignments and volunteer activities. You may exclude organizations that indicate race, color, religion, gender, national origin, disabilities, or other protected status. Attach additional sheets if necessary.

Employer Name/Address

Dates Employed
From To

Work Performed

1.

Telephone Number(s)

Hourly Rate/Salary
Starting Final

Your Job Title

Your Supervisor

Reason for Leaving:

Employer Name & Address

Dates Employed
From To

Work Performed

2.

Telephone Number(s)

Hourly Rate/Salary
Starting Final

Your Job Title

Your Supervisor

Reason for Leaving:

Employer Name & Address

Dates Employed
From To

Work Performed

3.

Telephone Number(s)

Hourly Rate/Salary
Starting Final

Your Job Title S: HR Application 4/13

Your Supervisor 3

Reason for Leaving:

About You
Summarize special job-related skills and qualifications acquired from employment or other experience. List professional, trade, business or civic activities and offices held. You may exclude membership that would reveal gender, race, religion, national origin, age, ancestry, disability or other protected status.

References Familiar with Your Work

Name 1. 2. 3. Occupation Address Phone

US Military Service
Branch
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Rank

Years of Service

Discharge Type
4

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Applicants Statement
I certify that the answers given herein are true and complete to the best of my knowledge. I authorize investigation by the company of all statements contained in this application for employment as may be necessary in arriving at an employment decision including performing reference and criminal background checks. I authorize my current and former employers to release any information contained in my personnel file or otherwise known by them to United Nursing Service, Inc. & UNS Home Health Agency, Inc. in connection with my application for employment with United Nursing Service, Inc. & UNS Home Health Agency, Inc. I specifically release from liability any current or former employers, their agents, representatives, employees, officers or directors, for giving such information to United Nursing Service, Inc. & UNS Home Health Agency, Inc.. This application for employment shall be considered active for a period of time not to exceed six months. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time. 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 the Executive Director of the company. 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. READ CAREFULLY BEFORE SIGNING: I agree that any action, claim or suit against United Nursing Service, its parent company or subsidiaries, arising out of my employment or the termination of my employment, including but not limited to claims arising under State or Federal civil rights statutes, must be brought within 180 days of the event giving rise to the claims or they will forever be barred. I waive any limitation periods to the contrary.

Applicant Signature

Printed Name

Date
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Consent and Release

The undersigned applicant hereby authorizes United Nursing Service, Inc. & UNS Home Health Agency, Inc. to conduct through its designated physician, medical facility, or laboratory testing facility a drug-screening test as a requirement for employment. In applying for employment I, __________________________________________, understand that a urine and drug screening test will be administered as part of the preemployment process to determine the presence of certain drugs and substances prohibited by United Nursing Service, Inc. & UNS Home Health Agency, Inc. Company Policy, such as, illegal drugs, controlled substances, marijuana, mood or mind-altering substances, look-alike substances, designer or synthetic drugs, certain inhalants and unauthorized prescription drugs. I further understand that the presence of one or more of these drugs or substances will disqualify me from further consideration for employment. I understand that refusal to submit to the drug screening test will constitute voluntary withdrawal of my application for employment. I authorize that the results of this drug-screening test be given to United Nursing Service, Inc. & UNS Home Health Agency, Inc. or any of its agents for employment purposes. I release and hold harmless the designated physician, testing laboratory, and/or medical facility for release of this information to United Nursing Service, Inc. & UNS Home Health Agency, Inc.. I also release and hold harmless United Nursing Service, Inc. & UNS Home Health Agency, Inc., its directors, officers, and employees for the use of this information for employment purposes. This Consent and Release shall be ongoing and constitute my consent to drug and alcohol screening at any time during my employment, consistent with United Nursing Service, Inc. & UNS Home Health Agency, Inc. Drug-Free Workplace Policy.

Applicant Signature

Printed Name

Social Security Number

Date

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