General Information


Employment History

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?
If yes, which state(s), and explain:
Do you have any pending charges against you?
If yes, 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?
If yes, 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?
If yes, please explain:

Certification of Applicant

Authorization for Investigation and Release - I authorize Christian Rest Home Association (CRHA) 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 CRHA 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 CRHA. 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 CRHA to conduct an investigation of me.