NURSING JOB APPLICATION

Serenity Health Training Institute 20245 W 12 Mile Rd,
Southfield, Michigan 48076 (248) 282-6562

Serenity Health Training Institute is an equal opportunity employer. This application will not be used for limiting or excluding any applicant from consideration for employment on a basis prohibited by local, state, or federal law. Should an applicant need reasonable accommodation in the application process, he or she should contact a company representative.

Please fill out all of the sections below:

Applicant Information

Applicant Name:

Address

Email

Date of Application:

Employment Position

Position(s) applying for: Nursing Instructors ( part time)

How did you hear about this position?

What days are you available for work?

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

What hours or shift are you available for work?

On what date can you start working if you are hired?

Do you have reliable transportation to and from work?

Yes

No

Salary desired:

Personal Information

Do you have any friends, relatives, or acquaintances working for Serenity Health Training Institute

Yes

No

If yes, state name & relationship:

Are you 18 years of age or older?

Yes

No

Are you a U.S. citizen or approved to work in the United States?

Yes

No

What document can you provide as proof of citizenship or legal status?

Will you consent to a mandatory controlled substance test?

Yes

No

Do you have any condition which would require job accommodations?

Yes

No

If yes, please describe accommodations required below.

Have you ever been convicted of a criminal offense (felony or misdemeanor)?

Yes

No

If yes, please state the nature of the crime(s), when and where convicted and disposition of the case:

(Note: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The date of the offense, the nature of the offense, including any significant details that affect the description of the event, and the surrounding circumstances and the relevance of the offense to the position(s) applied for may, however, be considered.)

Job Skills/Qualifications

Please list below the skills and qualifications you possess for the position for which you are applying:

(Note: Serenity Health Training Institute complies with the ADA and considers reasonable accommodation measures that may be necessary for eligible applicants/employees to perform essential functions. It is possible that a hire may be tested on skill/agility and may be subject to a medical examination conducted by a medical professional. )

Education and Training

High School

Name

Location (City, State)

Year Graduated

Degree Earned

College/University

Name

Location (City, State)

Year Graduated

Degree Earned

Vocational School/Specialized Training

Name

Location (City, State)

Year Graduated

Degree Earned

Military:

Are you a member of the Armed Services?

Yes

No

Previous Employment

Employer Name:

Job Title:

Supervisor Name:

Employer Address

Employer Telephone:

Dates Employed:

Reason for leaving:

Employer Name:

Job Title:

Supervisor Name:

Employer Address

Employer Telephone:

Dates Employed:

Reason for leaving:

Employer Name:

Job Title:

Supervisor Name:

Employer Address

Employer Telephone:

Dates Employed:

Reason for leaving:

References

Please provide 2 personal and professional reference(s) below:

Reference 1

Contact Information 1

Reference 2

Contact Information 2

Additional Information:

Name of courses taught and where?

AT-WILL EMPLOYMENT

The relationship between you and the Serenity Health Training Institute is referred to as "employment at will." This means that your employment can be terminated at any time for any reason, with or without cause, with or without notice, by you or the Serenity Health Training Institute. No representative of Serenity Health Training Institute has authority to enter into any agreement contrary to the foregoing "employment at will" relationship. You understand that your employment is "at will," and that you acknowledge that no oral or written statements or representations regarding your employment can alter your at-will employment status, except for a written statement signed by you and either our Executive Vice-President/Chief Operations Officer or the Company's President.

Applicant Signature:

Dated:

NURSING JOB APPLICATION

Your form has been submitted. Thank You!