Application

Name*

First Last

Address*

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

Phone*

Email*

Which location are you interested in?

Position Applying For

Are you 18 years of age or older?*

Yes

No

Do you have a valid Michigan driver's license?*

Yes

No

Can you perform the duties as described in the job description without accommodations?*

Yes

No

Working any shift and overtime is expected for continued employment. Are you able to meet this requirement?*

Yes

No

We are licensed to provide care 24 hours a day, 7 days a week, 52 weeks a year.

Accomodations Needed:

Have you ever been convicted of a misdemeanor or felony?*

Yes

No

Have you ever been administratively determined by a federal, state, or local government agency to have committed abuse or neglect?*

Yes

No

Have charges ever been substantiated against you for abuse, neglect, exploitation, mishandling client funds, or any other recipient rights violations in an investigation by the Department of Health & Human Services or any other Recipient Rights Office?*

Yes

No

Have you ever been employed by Valley Residential Services before?*

Yes

No

When, and under what name?

Do you have any relatives already employed by Valley Residential Services?*

Yes

No

What is their name?

Were you referred by one of our employees?*

Yes

No

What is their name?

Highest Level of Education*

Less than GED or High School Diploma

GED or High School Diploma

Associates Degree

Certificate or Trade Program

Bachelor’s Degree

Master’s Degree

Doctorate Degree

Course of Study

Resume

Accepted file types: doc, docx, pdf, Max. file size: 10 MB.

Cover Letter

Accepted file types: doc, docx, pdf, Max. file size: 10 MB.

Interview Questions

Completed Interview Questionnaire

Accepted file types: doc, docx, pdf, Max. file size: 10 MB.

The Interview Questionnaire can be found at the top of this page. This is not required, but will help expedite the hiring process.

Professional Reference #1

Employer*

Supervisor Name*

Phone*

Job Title*

Professional Reference #2

Employer*

Supervisor Name*

Phone*

Job Title*

Professional Reference #3

Employer

Supervisor Name

Phone

Job Title

Conditional Job Offer

I agree to the conditions of this job offer

#1 Pursuant to the Adult Foster Care Facility Licensing Act (AFCFLA) and its amendments, this
good faith offer of employment is conditioned upon the employer’s ability to successfully
establish the applicant’s eligibility for employment. Good moral character, criminal history, reference
checks and other indicators of overall suitability to work with vulnerable adults clearly conclude that the
applicant meets the standards of the AFCFLA and the employer’s personnel policies. This conditional job
offer is also conditioned upon the applicant’s timely cooperation with the obtainment of acceptable
personal identification, signed releases, consent forms, criminal history records, fingerprinting and
background checks as imposed by Public Act 29 of 2006, and any other employer personnel practices.
Failure to comply fully with all of the requirements within 10 days will result in withdrawal of this offer.
#2 (a) In accordance with the provisions of the Americans with Disabilities Act, Valley Residential Services
is making a conditional job offer to the applicant for the position. The offer of employment is conditioned upon successful completion of a
medical examination. This medical examination is given to all individuals in the position for which you have
applied.
(b) Such medical examination will be conducted at a medical facility selected by Valley Residential Services
and will be paid directly by Valley Residential Services.
(c) Any information gathered from the medical evaluation will be kept confidential and disclosed only as
lawfully permitted and maintained separate from your personnel files.
(d) The medical examination will be related to the essential functions of the job for which you have applied
and this conditional offer.
(e) If your medical condition warrants we may ask you to apply to become certified as vocationally
rehabilitated under Chapter 9 of the Michigan Workers Compensation Act.
(f) Valley Residential Service is an equal opportunity employer and will not discriminate on the basis of race,
sex, religion, national origin, marital status, age, weight, height, color, handicap, or genetic information in
the hiring of employees.
(g) This conditional job offer does not alter in any way the At Will status of employment. If the medical
evaluation is not complete within 30 days then the offer shall be withdrawn.

Application Form

Interview Questions

Professional Reference #1

Professional Reference #2

Professional Reference #3