210 N. Lake Street Boyne City, MI 49712 Tel: 231.582.2225 Fax: 231.582.6442

Application

SUMMERTREE RESIDENTIAL CENTERS, INC.
EMPLOYMENT APPLICATION

Summertree Residential Centers, Inc. is an equal opportunity employer and does not discriminate on the basis of age, sex, race, religion, color, national origin, disability, marital status, height, weight, veteran status or other legally protected status.

If you have a disability that impairs your ability to be considered, interviewed or tested for a position, please let us know what accommodations you may require.

Please complete the entire application and sign the Authorization and Understanding at the end of the application. If there is not enough space on this form to supply all the information necessary to answer a question or supply the complete information, please attach additional pages.

Date

Name

Present Address

City

State

Telephone Number

Cell Phone Number

Please supply any other names you have used in school or any previous job.

EDUCATION

High School

Name

Address

Curriculum

Did you Graduate? Yes No

College

Name

Address

Curriculum

Did you Graduate? Yes No

Other

Name

Address

Curriculum

Did you Graduate? Yes No

Are you presently attending school or plan on furthering your education in the future? If yes, please specify course and time commitment.

Please list any other experiences, skills, or qualifications you feel that qualify you for work in this setting.

NOTE TO APPLICANTS: DO NOT ANSWER THIS QUESTION UNLESS YOU HAVE BEEN INFORMED ABOUT THE REQUIREMENTS OF THE JOB FOR WHICH YOU ARE APPLYING.

Are you able to perform, with or without accommodation, the essential functions involved in the job for which you have applied:
Yes No

If no, please explain

If the position you are applying for requires a driver's license, please answer the following questions:

Do you currently have a valid driver's license?
Yes No

If yes, please provide this information about your license. State which issued license:

Driver's license number: Expiration date:

Have you received any tickets for moving violations in the past five years?
Yes No

If yes, please describe the violation(s), date and the circumstances:

Have you ever been convicted of a crime, excluding routine traffic offenses?
Yes No

(Answering yes to this question will not automatically disqualify you)

If yes, describe in detail:

Are there currently any charges pending against you?
Yes No

If yes, describe in detail:

Are you currently on a court supervised probation or parole?
Yes No

If yes, explain in detail:

Have you ever been administratively determined by a federal, state, or local government agency to have committed abuse or neglect?
Yes No

If yes, describe when, where and the nature of the case.

Are you currently or have you ever been the subject of a Department of Human Services investigation?
Yes No

If yes, explain in detail the investigation:

Are you currently or have you ever personally been investigated by the Department of Human Services Adult Protective Service Unit, Department of Mental Health Recipient Rights Office, a Community Mental Health Recipient Rights Office or any other recipient rights office?
Yes No

If yes, explain in detail the investigation:

Do you hold any professional licenses or certifications? Yes No

If so describe your qualification:

Have you ever had a professional license or certification revoked or suspended? Yes No

If so describe the circumstances leading to the action.

Are you currently under any agency or departmental investigation concerning any licensure or certification matter? Yes No

If yes, explain in detail:

EMPLOYMENT HISTORY

Start with most recent; list entire employment history and military service; attach additional pages if necessary.

Company Name

Address

Telephone

Dates of Employment

Position

Duties

Supervisor

Reason for Leaving

Are you currently employed? Yes No

May we contact your current employer? Yes No

REFERENCES

Give the names of two personal references from persons not related to you, whom you have known at least one year.

Name

Address

Telephone

Name

Address

Telephone

Give the names of two professional references from supervisors or managers for whom you have worked.

Name

Address

Telephone

Name

Address

Telephone

Authorization and Understanding

I represent that the answers and information given by me in this application are true and complete. I understand that any incomplete, misleading or false statements in this application or in an interview can result in immediate disqualification or termination, if hired.
      
      I authorize Summertree Residential Centers, Inc. to verify the information I have provided and to make any investigation of my background deemed necessary, both at the time of application and later during my employment, if I am hired. I understand Summertree will perform a criminal record report. I understand that I may have to provide further information to assist in this investigation and I may be fingerprinted. I understand that I have the right to request certain information about the nature and scope of the report and the name and address of the agency making the report. I also authorize third parties (such as former employers, law enforcement organizations, educational institutions) contacted by Summertree to furnish any information relevant to my application for employment and I further release all persons and organizations from any and all liability for any and all damages whatsoever for releasing such information. I also waive all written notice from all prior employers related to providing such information. I also understand that because of the nature of my job and licensing requirements, I hereby consent to the release of this application and my employment file, as it directly pertains to employment with Summertree, to representatives of the Adult Foster Care Licensing, Community Mental Health, Department of Community Health and or any other governmental agencies. I hereby waive any obligation and expect no written notice of disclosure of my personal information.
      
      I have no objection to signing an employee agreement on confidential information. I consent to all medical examinations and drug and alcohol testing required by Summertree, both during the selection process and throughout employment, if I am later hired.
      
      I understand and agree that employment with Summertree is at will and that either I or Summertree can terminate my employment and compensation, with or without cause, and with or without notice, at any time. I acknowledge that no representations, either oral or written, have been made to me to the contrary and that any pre-existing understandings which contradict an at will status of employment are canceled. Further, I understand that only the Executive Director has any authority to enter into any agreement for employment for any fixed period of time, or to make any agreement contrary to the foregoing and that any such agreement must be in writing and signed by the Executive Director and me.
      
      In consideration of my employment, I agree to conform to the rules and policies of Summertree. Also, I agree not to begin any action or suit relating to employment with Summertree more than six months after the date of the termination of such employment and I waive any statute of limitations to the contrary. This application for employment shall be considered active for 12 months. If I wish to be considered for employment after that time period, I should inquire at that time whether or not applications are being accepted.

I have read and understand the above paragraphs. Yes No

Application

SUMMERTREE RESIDENTIAL CENTERS, INC. EMPLOYMENT APPLICATION

EDUCATION

EMPLOYMENT HISTORY

REFERENCES

Authorization and Understanding

SUMMERTREE RESIDENTIAL CENTERS, INC.
EMPLOYMENT APPLICATION