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Employee Questionnaire for Voluntary Self-Identification

Name Other Name(s) Used (Maiden Name) Date Phone Number Email Present Address Previous Address How long have you lived at present address? How long have you lived at previous address? Position(s) you are applying for Rate of pay expected per hour Preferred Work Status Full-timePart-timeFlex (On-call) Preferred Shift DayAfternoonMidnightWeekendsStudent Please Provide Your Preferred Choice Were you previously employed by Allegria Senior Living? If yes, what years? Have you previously interviewed with Allegria Senior Living? If yes, what years? Do you have any friends or relatives working for Allegria Senior Living? If yes, list names How did you hear about this position? What date can you begin work?

Please list present and past employment, beginning with your most recent. Please provide all information in full even when submitting a resume Company One Company Name Company Address Company Phone Number Supervisor Name Position Held Start Date End Date Reason for leaving Company Two Company Name Company Address Company Phone Number Supervisor Name Position Held Start Date End Date Reason for leaving Company Three Company Name Company Address Company Phone Number Supervisor Name Position Held Start Date End Date Reason for leaving Company Four Company Name Company Address Company Phone Number Supervisor Name Position Held Start Date End Date Reason for leaving May we contact your former employers? If not, which employers do you not want us to contact? Why would you like to work at Allegria Village?

High School Name of School State Did you graduate? GED Where State College Name State How long? Course of study> Degree Other Education Name How long? Course of study> Degree/Diploma Certifications or Licensures List any other experiences, skills, or qualifications that may benefit our organization

Were you in the US Armed Forces? If so, what branch? Dates of duty Rank at discharge List duties in the service

Do you have any scheduling restrictions? If yes, please explain Are you legally authorized to work in the United States? Proof of U.S. Citizenship or immigration status will be required upon employment). Have you ever been convicted of a crime within the past 15 years or misdemeanor within 10 years, that has not been annulled, expunged, or seal by court? (Such convictions may be relevant if job-related, but do not bar you from employment unless covered under Michigan Public Act 28 of 2006). If yes, please explain If offered a position, do you agree to submit to a drug screen and fingerprinting?

NO RELATIVES PLEASE. At least one reference is required to submit the application. Reference One Name Company Occupation/Title Company Address Phone Number Reference Two Name Company Occupation/Title Company Address Phone Number Reference Three Name Company Occupation/Title Company Address Phone Number Reference Four Name Company Occupation/Title Company Address Phone Number Please Read & Sign Below

The above information is true and correct. I understand that, in the event that I become employed by Allegria Senior Living, I shall be subject to dismissal if any information that I have given in this application is false or misleading or if I have failed to give any information herein requested, regardless of the time elapsed after discovery. I hereby give my consent to any former employer to provide employment-related information about me to Allegria Village including but not limited to: my past employment. I authorize all persons and organizations to release any information concerning my background and hereby release all persons and organizations from liability for any damage whatsoever for issuing this information. I acknowledge that a telephone facsimile(FAX) or photographic copy shall be valid as the original and will hold Allegria Senior Living and my former employer harmless from any claim made on the basis that such information about me was provided or that any employment decision was made on the basis of such information. I further authorize Allegria Senior Living to obtain credit and consumer check information. I understand that this employment application does not create an employment contract between me and Allegria Senior Living. I also understand and agree that, if hired, my employment may be terminated by me or Allegria Senior Living at any time and for any reason. I understand that no person has any authority to enter into any agreement contrary to the foregoing. If employed, I will be required to provide original documents that verify my identity and right to work in the United States under the Immigration Reform and Control Act (IRCA) of 1986. The document(s) provided will be used for completion of Form-I-9.

I hereby acknowledge that I have read and agree to the above statements. Signature Date

Name Date Instructions

Please read ALL instructions carefully before completing this form.

Voluntary Notice: Allegria Senior Living is subject to certain governmental recordkeeping and reporting requirements for the administration of civil rights laws and regulations. In order to comply with these laws, we invite our employees to voluntarily self-identify their gender and race or ethnicity. Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information obtained will be kept confidential and may only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information to be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.

Gender Please select one of the options below MaleFemaleI choose not to disclose Race Are you Hispanic or Latino (a person of Cuban, Mexican, Chicano, Puerto Rican, South or Central American, or other Spanish culture of origin, regardless of race)? If you answered YES, you have completed this form. If you answered NO, please select a race from the options below White (Not Hispanic or Latino)Black or African (Not Hispanic or Latino)Native Hawaiian or Other Pacific Islander (Not Hispanic or Latino)Asian (Not Hispanic or Latino)American Indian or Alaska Native (Not Hispanic or Latino)Two or More Races (Not Hispanic or Latino)I choose not to disclose You have reached the end of the application. Please submit it using the button below and we will get back to you as soon as possible. Thank you!

Anti-Discrimination Notice: It is an unlawful employment practice for an employer to fail or refuse to hire or discharge any individual, or otherwise to discriminate against any individual with respect to that individual’s terms and conditions of employment, because of such individual’s race, color, religion, sex, or national origin. Henry Ford Village is an equal opportunity employer, we hire without consideration to race, religion, creed, color, national origin, age, gender, sexual orientation, marital status, veteran status, or disability.

You must be 18 years or older to be employed by Allegria Senior Living. Under 18 requires a work permit. Signature Date