Employment Application – Direct Care Worker

Please fill out the employment application below and click submit. Thank you for taking the time to apply for our position. We appreciate your interest in Senior Services. If we feel you are a good fit, we will contact you for an interview.

Any questions should be directed to Pat McDonald, Human Resources Director at 989-633-3715 or pmcdonald@mccoa.org.

Employment Application - Direct Care Worker

"*" indicates required fields

Mission Statement

To promote and enrich the quality of life for older adults and those who care for them by collaboratively providing meaningful services and opportunities.

Answer all questions. If more space is needed to answer questions completely, attach a separate sheet. Notify this office promptly if your address or telephone number changes.

Senior Services, Midland County Council on Aging, considers all applicants for employment without regard to race, color, religion, sex, national origin, age, handicap or disability, or status as a Vietnam-era or special disabled veteran in accordance with federal law. In addition, Senior Services complies with applicable state and local laws prohibiting discrimination in employment in every jurisdiction in which it maintains facilities. Senior Services also provides “reasonable accommodations” to qualified individuals with disabilities, in accordance with the Americans with Disabilities Act and applicable state and local laws. Employment is contingent on being fully vaccinated for Covid 19.

Position applying for:*

Date available to start:*

Applicant's Name*

First Middle Last

Residence Address

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

Home or Cell Phone*

Work Phone

Email*

Are you 18 years of age or older?*

Yes

How did you hear about the position?

Facebook

Twitter

Indeed

Newspaper advertisement

Senior Services' website

Word of mouth

Have you ever been employed by Senior Services before?*

Yes

If yes, in which department and when:

Are any persons currently employed by Senior Services related to you by blood or marriage?*

Yes

If yes, give names and your relationship to them:

Are there any felony charges pending against you?*

Yes

If yes, please explain:

Have you ever been convicted of a crime?*

Yes

Start with your most recent position and work back. In the space below, give your complete record of employment. Include periods of job-related military service and explain any gaps between periods of employment. If there is an experience requirement for the job, be sure to show clearly that you meet such a requirement.

You must fill out this section even if attaching a resume.

Describe in detail the tasks you performed. (Approximate date range is acceptable)

Employer 1

Where were you employed?*

Date of Employment From:*

Date of Employment To:*

State your exact title.*

Name of Supervisor & Title*

Employer Address:*

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

Describe your duties:*

Salary Start/Finish:*

Reason for Leaving:*

Employer 2

Where were you employed?

Date of Employment From:

Date of Employment To:

State your exact title.

Name of Supervisor & Title

Employer Address:

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

Describe your duties:

Salary Start/Finish:

Reason for Leaving:

Employer 3

Where were you employed?

Date of Employment From:

Date of Employment To:

State your exact title.

Name of Supervisor & Title

Employer Address:

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

Describe your duties:

Salary Start/Finish:

Reason for Leaving:

Employer 4

Where were you employed?

Date of Employment From:

Date of Employment To:

State your exact title.

Name of Supervisor & Title

Employer Address:

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

Describe your duties:

Salary Start/Finish:

Reason for Leaving:

Employer 5

Where were you employed?

Date of Employment From:

Date of Employment To:

Have you ever served in the U.S. Armed Forces?*

Yes

List duties in the Service, including special training that is relevant to the position for which you have applied:

Skills Section

If an essential function of the job, please list your computer skills (i.e., proficiency with word processing, spreadsheet, database, publishing and presentation software), typing skills (wpm), shorthand (wpm), other office equipment:*

Please list any other experiences, skills, or abilities that you feel especially qualify you for work with Senior Services:

Do you have a valid State of Michigan driver’s license?*

Yes

Do you have valid proof of auto insurance?*

Yes

Traffic Violations

List all traffic violations you have had within the last five (5) years. If no traffic violations, please check the box below and skip this section.

Have you had any traffic violations within the last 5 years?*

Yes

1. List Offense and Month/Year it occured:

2. List Offense and Month/Year it occured:

3. List Offense and Month/Year it occured:

References(excluding relatives)

Reference 1

Name*

First Last

Occupation*

Date Known From:*

Date Known To:*

Phone*

Reference Type:*

Personal

Professional

Reference 2

Name*

First Last

Occupation*

Date Known From:*

Date Known To:*

Phone*

Reference Type:*

Personal

Professional

Reference 3

Name*

First Last

Occupation*

Date Known From:*

Date Known To:*

Phone*

Reference Type:*

Personal

Professional

Pre-Employment Statement

(Please read carefully and sign the statement below)

Consent*

I agree to the policy stated below.

I certify that the facts set forth in this Application of Employment, in my resume and in the other materials I have submitted are true and complete. I understand and acknowledge that false information provided by me will result in disqualification from employment with Senior Services, Midland County Council on Aging (hereinafter “the Employer”) or in dismissal from employment if an offer of employment has been made and accepted.

I hereby authorize the Employer, to contact all my former and current employers, educational institutions and the other references I have provided regarding me and my performance record and work, academic and/or military experience. I also hereby release the Employer and its employees and agents, and all of my former and current employers, educational institutions, and the other references I have provided, from any and all liability and damages for releasing or using information concerning me and my performance record and work, academic and/or military experience. I also hereby waive any right under the Bullard-Plawecke Right to Know Act, 1978 PA 397, to receive written notice from the Employer or any former or current employer, that disciplinary reports, letters of reprimand, or other disciplinary action taken against me while employed, will be or have been disclosed to a third person or entity.

I also understand that the Employer may, in its sole discretion, conduct or have conducted by an individual or entity of its choice, a conviction-only criminal background history search on me, and a check of my driving record. I hereby consent to these searches being conducted and to the disclosure of those results of these searches by the individual or entity conducting the search of the Employer. I further hereby release the individual or entity conducting the search, the Employer, and it employees and agents, from any and all liability, claims and damages, including but not limited to claims for releasing or using any information revealed as a result of this search. I also understand and acknowledge that convictions may result in disqualification from employment with the Employer or in dismissal from employment if an offer of employment has been made and accepted.

In consideration of my employment, I agree and understand that my employment and compensation can be terminated with or without cause, with or without notice, at either my option or at the option of the Employer, it being mutually understood and agreed that my relationship with the Employer is one of employment at will.

If I am employed, I understand that additional personal data will be required for determination of benefit eligibility and for statistical purposes.

I will abide by all policies, rules and regulations of the Employer.

Full Name*

Signature*

Date*

Attach Resume, Cover Letter and/or additional References

Drop files here or

Max. file size: 10 MB.

CAPTCHA

Senior Services, Midland County Council on Aging, is an Equal Opportunity Employer and will not unlawfully discriminate against any individual due to age, gender, race, religion, sexual orientation, gender identity, national origin, genetic information, veteran status, pregnancy, disability, color, height, weight, familial status, marital status, or any other protected status.

Download Background Check Form

*Print, complete the background check form and bring with you to your interview. Do not send the form electronically.

Senior Services, Midland County Council on Aging, will not unlawfully discriminate against any individual due to age, gender, race, religion, sexual orientation, gender identity, national origin, genetic information, veteran status, pregnancy, disability, color, height, weight, familial status, marital status, or any other protected status.

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Employment Application – Direct Care Worker