Apply - Golden Life

First Name

Middle Name

Last Name

Suffix

Other Name(s) Used (Maiden Name,Alias)?

Yes

First Name

Middle Name

Last Name

Address

Address Line 2

City

State

Zip Code

Primary Phone

Background Check

This employment applicant information is required to process a complete and accurate criminal record check.

Date of Birth

Country of Citizenship

Height

Eye Color

Hair Color

Race

Social Security Number

Place of Birth (City, State/Province)

Weight

Gender

Drivers Licence/State ID

State of Issue

Have you resided in Michigan continuously for the past 12 months?

Yes

Previous Employment

How many previous employers?

Name of Employer

Address

Start Date

Phone Number

Name of Supervisor

Last Job Tile

Current Employer

Yes

End Date

May we contact this employer?

Yes

Reason for Leaving

List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:

Name of Employer

Address

Start Date

Phone Number

Name of Supervisor

Last Job Tile

End Date

May we contact this employer?

Yes

Reason for Leaving

List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:

Name of Employer

Address

Start Date

Phone Number

Name of Supervisor

Last Job Tile

End Date

May we contact this employer?

Yes

Reason for Leaving

List the jobs you held, duties performed, skills used or learned, advancements, or promotions while you worked at this company:

Education & Experience

Please list any additional experiences, skills and qualifications which you believe relate to the job(s) for which you are applying:

Highest Level of Education?

High School

Completed?

Yes

Mailing Address

Major or Degree

College or Trade School

Completed?

Yes

Mailing Address

Major or Degree

Other Training

Completed?

Yes

Mailing Address

Major or Degree

Professional License(s)/Certification(s)

1. License/Certification Number

2. License/Certification Number

3. License/Certification Number

Please list any academic honors you have received which you believe relate to the position you are applying for:

Applicant Disclosure Statements

MCL 333.20173a, MCL 330.1134a, and MCL 400.734b, subsections (1)(a) through (g) describe crimes for which a conviction during the applicable time period will disqualify a person from being employed by, independently contracting with, or being granted clinical privileges in a covered health care facility/agency or AFC.
The above laws define “conviction” as, “... a final conviction, the payment of a fine, a plea of guilty or nolo contendere (no contest) if accepted by the court, or a finding of guilt for a criminal law violation or a juvenile adjudication or disposition by the juvenile division of probate court or family division of circuit court for a violation that if committed by an adult would be a crime.” For relevant crimes described under 42- USC 1320a-7(a), convicted means that term as defined in 42-USC 1320a-7. These definitions may include cases that resulted in an alternative sentencing agreement, including deferred or delayed sentences, and for relevant crimes under 42-USC 1320a-(7)(a), convictions which may have been expunged or set aside.

A) I hereby certify that I have not been convicted of 1 or more of the crimes described in subsection (1)(a) through (g) of MCL 333.20173a, MCL 330.1134a, or MCL 400.734b within the applicable time period described in each subdivision.

I agree

I disagree

B) I hereby certify that I have never been found Not Guilty by Reason of Insanity.

I agree

I disagree

C) I hereby certify that I have never been the subject of a substantiated finding of neglect, abuse, or misappropriation of property resulting from an investigation conducted in accordance with 42 USC 1395i or 1396r.

I agree

I disagree

If you are not able to certify a, b, or c above, please explain below:

Offense/Finding 1

Offense/Finding 2

Offense/Finding 3

Offense/Finding 4

Date 1

Date 2

Date 3

Date 4

City, State 1

City, State 2

City, State 3

City, State 4

Sentence 1

Sentence 2

Sentence 3

Sentence 4

Discharge Date 1

Discharge Date 2

Discharge Date 3

Discharge Date 4

References

Please list at least 3 references, other than relatives and previous employers, whom you have known for at least 1 year

Name

Company

Position

Phone/Mobile

Name

Company

Position

Phone/Mobile

Name

Company

Position

Phone/Mobile

Application Submission

Authorization

I certify that the facts set forth in this application are true, correct and complete without misrepresentations or omissions of any kind whatsoever. I authorize investigation of the statements I have made herein. I am applying for employment with The Company. I hereby authorize any and all persons (including any and all employers with whom I have been employed, schools that I have attended and organizations with which I have been connected) to release any and all information that have about me to Golden Life AFC, LLC.

Type Full Name for Signature

Apply to Golden Life

Background Check

Previous Employment

Education & Experience

Professional License(s)/Certification(s)

Applicant Disclosure Statements

If you are not able to certify a, b, or c above, please explain below:

References

Application Submission