Apply - Edison Christian Life Services - Edison Christian Life Services

General Information

Position Applied For*

Preferred Shifts*

1st shift (day)
2nd shift (evening)
3rd shift (night)

Preferred Status*

Full time
Part time

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Education

College/University Name and Location

Dates Attended

Degree

Technical School Name and Location

Dates Attended

Degree

High School Name and Location

Dates Attended

Degree

Employment History

Most Recent Employer

Dates

Position

Reason for Leaving

2nd Most Recent Employer

Position

Dates

Reason for Leaving

3rd Most Recent Employer

Position

Dates

Reason for Leaving

Professional Licenses, Registrations, or Certifications

Please include: Type, State, Date Received, Renewal Date, and Number

If applying for a CNA position, where did you receive your training?

Criminal History

Have you ever been convicted of, or pleaded guilty to, a crime?*

Yes
No

Which state(s), and explain:

Do you have any pending charges against you?*

Yes
No

Please explain:

Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of Michigan or any other state in the US?*

Yes
No

Which state(s), and please explain:

Have you been sanctioned or excluded from participation in Medicare, Medicaid, or any other healthcare related law or regulation?*

Yes
No

Please explain:

Certification of Applicant

Authorization for Investigation and Release - I authorize Edison Christian Life Services (ECLS) to conduct an investigation of me, including but not limited to, all statements made by me in this application. I authorize the any prior or current employer to give ECLS any and all information concerning my previous employment, including any disciplinary information and any other information that they may have, personal or otherwise. I release all parties from all liability for any damage that may result from furnishing information to ECLS. Also, I hereby waive written notice that employment information is being provided by any person or organization. A photocopy of this Authorization and Release shall be considered as effective as the original.

I acknowledge that I have read and understand the above statement and authorize ECLS to conduct an investigation of me.*

Yes
No

Please type your name and the date for your digital signature*

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General Information

Education

Employment History

Professional Licenses, Registrations, or Certifications

Criminal History

Certification of Applicant

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