Application for Employment

You can fill out the form below to submit your application. If you'd prefer to send in your application through the regular mail, you can download it as a PDF.

Your Full Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Email*
The Michigan Civil Rights Act and/or federal law prohibit discrimination in employment on the basis of: religion, race, color, disability, national origin, age, sex, height, weight, veteran status or marital status. Lake Superior Life Care & Hospice is an equal opportunity employer and does not discriminate on the basis of any of these or any other legally protected category or medical condition. Michigan law requires that a person with a disability requiring accommodation for employment must notify the employer in writing within 182 days after the need is known.
PERSONAL INFORMATION
Position(s) Desired*
Date Available*
MM slash DD slash YYYY
Expected Wage: (per hour)
Status (check all that apply)*
- Select All
- Full Time
- Part Time
- Irregular Part Time
- Temporary or Summer
From
MM slash DD slash YYYY
To
MM slash DD slash YYYY
Minimum number of hours you would like to work per week
Can you work the weekend?*
- Yes
- No
Can you work Holidays?*
- Yes
- No
Are there days/hours that you can't work?*
- Yes
- No
Please list and explain the days/hours you can't work*
Are you 18 years of age or older?*
- Yes
- No
Do you have the legal right to work and remain in the United States?*
- Yes
- No
Have you previously worked for Lake Superior Life Care & Hospice?*
- Yes
- No
Do you have a previous or alternate name? If so, Please indicate name:*
Do you have reliable transportation?*
- Yes
- No
Have you been the subject of any adverse action(s) by any duly authorized sanctioning or disciplinary agency for either conduct based or performance based actions? Have you had any previous involvement as a defendant in professional malpractice litigation, had your license revoked, or been subject to any disciplinary action against you?*
(Unless otherwise required by law, a conviction record will not necessarily be a bar to employment. Factors such as age at the time of the offense, length of time since conviction, seriousness and nature of violation, position applied for and rehabilitation will be considered.)
- Yes
- No
Please explain*
EMPLOYMENT HISTORY

Please list employment beginning with your present or most recent employer.
1. Present or Last Employer
Position Held
Address
Street Address City State ZIP Code
Employment Started
MM slash DD slash YYYY
Employment Ended
MM slash DD slash YYYY
May we contact?
- Yes
- No
Name of Supervisor
Department
Wage
Reason for Leaving
2. Present or Last Employer
Position Held
Address
Street Address City State ZIP Code
Employment Started
MM slash DD slash YYYY
Employment Ended
MM slash DD slash YYYY
May we contact?
- Yes
- No
Name of Supervisor
Department
Wage
Reason for Leaving
3. Present or Last Employer
Position Held
Address
Street Address City State ZIP Code
Employment Started
MM slash DD slash YYYY
Employment Ended
MM slash DD slash YYYY
May we contact?
- Yes
- No
Name of Supervisor
Department
Wage
Reason for Leaving
EDUCATIONAL DATA
Grade/High School (Name/address)
Highest grade completed
College/University (Name/address)
Highest grade completed
Degree/Title(s) earned
Other Pertinent Training
Foreign Language
Understand
Read
Speak
LIFE EXPERIENCE
Describe your own life experiences and feelings about death and dying and how care should be provided to the terminally ill.
REASONS FOR APPLICATION TO LAKE SUPERIOR HOSPICE
Please indicate your reasons for application to this hospice program. Include talents and interests which make you suited for this type of work.
PERSONAL REFERENCES

Please list three people who could be contacted as character references other than relatives.
1. Name
First Last
Occupation
Phone
Address
Street Address City State ZIP Code
2. Name
First Last
Occupation
Phone
Address
Street Address City State ZIP Code
3. Name
First Last
Occupation
Phone
Address
Street Address City State ZIP Code
EMERGENCY CONTACT INFORMATION
Contact 1
First Last
Phone
Relationship
Contact 2
First Last
Phone
Relationship
CERTIFICATION AND AUTHORIZATION

APPLICANT PLEASE READ CAREFULLY
I certify that the answers that appear on this application and the information provided in my resume are complete and true. I hereby authorize Lake Superior Life Care & Hospice and/or its agents to verify any or all of the information provided on this application and in my resume. In order to verify such information, I hereby authorize all persons, schools, companies and law enforcement agencies to release any records or any other information they may possess relating to my application for employment. I also release any individual, partnership or corporation which presently or formerly employed me, any school I attended, their officers, agents and employees and any law enforcement agency from any liability, claims or damages for issuing such information in good faith and without malice.

Should I become an employee at Lake Superior Life Care & Hospice, I also release Lake Superior Life Care & Hospice from any liability, claims, or damages for issuing such information in good faith and without malice to other individuals/institutions who have a legitimate and common interest in the subject matter.

I realize that falsification or omission of any information on this application, in my resume, or during any interview, will be grounds for rejection of my application or if I am offered employment, discharge at any time during my employment. I also understand that nothing in the application is intended to imply or create an employment relationship or contract for employment.

If offered employment, I will submit to any medical examinations and drug tests deemed necessary by Lake Superior Life Care & Hospice to evaluate my physical and mental fitness for employment. If employed, I will submit to any physical or mental examination or drug testing deemed necessary by Lake Superior Life Care & Hospice to determine my continued fitness to perform the duties of the job, or whenever such medical examinations are required by state or federal law. If employed, I agree to observe at all times all rules and regulations.

I acknowledge and agree that should I, once employed or as an employee, be subsequently arrested or convicted of one or more criminal offenses as listed below:
1. Attempt or conspiracy to commit a felony;
2. Misdemeanor, involving abuse, neglect, assault, battery or criminal sexual conduct involving fraud or theft against a vulnerable adult as defined in Section 145m of the Michigan Penal Code
I also agree to notify this employer in writing within twenty-four (24) hours of the criminal event.

I authorize Lake Superior Life Care & Hospice to conduct a thorough investigation of my past employment, background, criminal history, education, and activities. I agree to cooperate in such investigation and release and discharge from all liability, responsibilities, claims or damages of any kind or nature Lake Superior Life Care & Hospice and any other persons or entities requesting or supplying information pursuant to such investigation. I understand that, if I am offered employment, my employment will be contingent upon me successfully passing, in Lake Superior Life Care & Hospice’s discretion, any investigation conducted by Lake Superior Life Care & Hospice. I further authorize Lake Superior Life Care & Hospice to supply my employment record, in whole or in part, to any prospective employer, government agency, or other party with a legal or proper interest.
I have received the Covid-19 Vaccine
If you have received the COVID-19 Vaccine, please provide the date(s) below
I have resided in the State of Michigan for three (3) years immediately proceeding the date of this application:*
- Yes
- No
When did you move to the state of Michigan?*
MM slash DD slash YYYY
Untitled
Signature*
Attach Your Resume or Cover Letter
PDF or Word Document format, less than 8MB
Accepted file types: pdf, jpg, tiff, doc, docx, Max. file size: 10 MB.
“I understand that if I have a protected disability that affects my ability to do the job I seek, I may ask Lake Superior Life Care & Hospice to attempt to make a reasonable accommodation for it. I must make my request in writing to the Human Resources Department as soon as possible, and under the Michigan Persons With Disabilities Civil Rights Act, the notice must be given no later than 182 days after the date I know or reasonably should know that accommodation is needed.
“I understand that if I have a protected disability that affects my ability to do the job I seek, I may ask Lake Superior Life Care & Hospice to attempt to make a reasonable accommodation for it. I must make my request in writing to the Human Resources Department as soon as possible, and under the Michigan Persons With Disabilities Civil Rights Act, the notice must be given no later than 182 days after the date I know or reasonably should know that accommodation is needed.
Name
This field is for validation purposes and should be left unchanged.

Application for Employment

PERSONAL INFORMATION

EMPLOYMENT HISTORY

EDUCATIONAL DATA

LIFE EXPERIENCE

REASONS FOR APPLICATION TO LAKE SUPERIOR HOSPICE

PERSONAL REFERENCES

EMERGENCY CONTACT INFORMATION

CERTIFICATION AND AUTHORIZATION