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Pre-Employment Questionnaire

You must answer all questions completely. Failure to do so will result in rejection of you application and you will not be considered for employment.


Position(s) Applied for:

Name:
Last

First

Middle

Address:
Street

City

State

Zip

Telephone:

Cell:

Email:

Soc. Security # :

Driver’s License # :

Are you prevented from lawfully becoming employed in this country because of Visa or Immigration status? (Proof of citizenship or immigration state may be requested upon offer of employment)



Are you available



Will you submit to a drug test?



Have you ever been convicted of a misdemeanor or felony, other than traffic violations? 



If Yes, give complete description, including location(s) and date(s)

Are there any outstanding legal proceedings or pending judgments against you? 



*Note: A conviction record will not necessarily disqualify you from employment, factors such as age, time of offense, seriousness and nature of violation, and rehabilitation will be considered.


General


Are you 18 Years or older? 



Have you ever applied with or worked for A+ Nursing, Inc. in the past?



If Yes, give date(s) and stop the application and notify office staff

Are you employed now? 



Are you on lay off? 



If yes, are you subject to recall?




Do You have any limitations that could prevent you from meeting your job descriptions?



If Yes, Explain

Do you speak, read, or write any other language, besides English?



If yes, indicate languages, and level of ability (Fluent, Good, Fair)


Speak
Read
Write


Education/Training


School Name And Location (High School)
School Name And Location (Vocational or Technical)
School Name And Location (College/Graduate)

Did you Graduate



Describe any specialized training, apprenticeships, internships, skills, license, certificates and extra-curricular activities that pertain to the position(s) for which applying:


Military Service Record


Have you had any experience in the Armed Forces?



If yes, List Branch

Currently Enlisted:



Rank upon Discharge:

Date of Discharge:

Were you honorably discharged?



*Note A dishonorable discharge from military w ill not necessarily be a bar to employment.



Employment History

List Each Job held, starting with the most recent or current

Employer:

Position Held:

Supervisor:

Phone:

From dates:

To dates:

Hourly Rate or Salary Start:

Hourly Rate or Salary End:

Work Performed:

Employer:

Position Held:

Supervisor:

Phone:

From dates:

To dates:

Hourly Rate or Salary Start:

Hourly Rate or Salary End:

Work Performed:

Employer:

Position Held:

Supervisor:

Phone:

From dates:

To dates:

Hourly Rate or Salary Start:

Hourly Rate or Salary End:

Work Performed:


References

Do not include relatives or former employers


Name #1:

Phone:

Years Acquainted:

Name #2:

Phone:

Years Acquainted:

Name #3:

Phone:

Years Acquainted:


Specialized Experience


Applicant’s Statement


I certify that the answer’s given herein are true and complete to the best of my knowledge. The undersigned hereby authorizes all past or present employer indicated in the employment history section to release to this prospective employer, any and all information contained in my personal records and to communicate to this prospective employer, any and all information within its knowledge. The undersigned further releases the employer(s) from any and all liability or claims arising from the release of this information, and also waives the provisions of the M ichigan Bullard-Plawecki Employee Right to Know Act requiring the Employer(s) to notify the undersigned of release of such information.


I understand that completion of application is not an offer of employment. And that if I am hired, the employment is conditional based on the policies and standards of the company. And that the employment relationship may be terminated at any time for any reason as outlined in such policies and standards, with or without notice and with or without cause by either the employer or me.


In the event of employment, I understand that false or misleading information given in the application or interview (s) may result in discharge. I understand that offer of employment is conditional upon the results of a thorough criminal record search, finger printing, and drug screen. I understand that I must abide by all rules and regulations outlined in the policies of the employer.


Applicant Signature

Date


Get Connected


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A+ Nursing, Inc. is a Kalamazoo-based, privately owned corporation with highly trained, dependable health care staff of Registered Nurses, Licensed Practical Nurses, State-Certified Nursing Assistants and Home Health Aides. Our Mission is to meet the medical, spiritual and emotional needs of our clients by providing care “A Grade Above The Rest” to maintain their quality of life. We deliver care with Passion, Honesty, and respect.


(800) 531-0272


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