Application For Employment

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Bay County Medical Care Facility is an Equal Opportunity Employer. It is the policy of the Facility to afford equal employment opportunities, regardless of a person’s race, religion, color, national origin, sex, disability, genetic information, marital status, height, weight, familial status, veteran status, or any other legally protected characteristic. A person with a disability requiring an accommodation in the application process should notify the Facility’s Human Resources Department.

The accurate and thorough completion of this application is an important step in our consideration of applicants for employment. Please complete the entire application. I understand that providing information not specifically asked for in this application, or not relevant to the question asked, will disqualify my application from being considered for employment. “See resume” is not an appropriate response to a question. Additional paper is available if you need to explain or detail any response.

Application for Employment

Step 1 of 4

Applicant Information

Position Applied For

Last Name

First Name

Middle Name

Home Phone

Cell Phone

What prompted your application?

Referred by

Have you ever applied with us before?

Yes

When did you apply?

What position did you apply for?

Have you ever been employed by the Bay County Medical Care Facility?

Yes

From (month and year)

To (month and year)

Reason for Leaving

Salary Expectation

Date Available for Work

Available for

Full Time

Part Time

Per Diem

Please indicate any previous names or nicknames necessary to verify information included in this application

Are you related to or know anyone who works for Bay County Medical Care Facility?

Yes

Please name the individuals

Are you willing to work variable, rotating shifts and weekends?

Yes

Specify any dates or times you are unavailable for work.

Do you have any responsibilities other than work that may interfere with our job requirements?

Yes

Please explain

Do you have a reliable form or transportation to get to work?

Yes

Are you 18 years of age or older?

Yes

Are you legally eligible for employment in the United States?

Yes

Are you able to perform the essential duties of the job for which you are applying with or without reasonable accommodation?

Yes

Are you currently on "layoff' status and subject to recall?

Yes

Have you ever been discharged by an employer or resigned in lieu of discharge?

Yes

Have you ever been disciplined for violations of company policy?

Yes

If you answered yes to either of the two previous questions, explain all such incidents, giving facts, dates, describing any action you took and any resolution on an attached signed statement.

Employment History

List your last four employers or all employers for the last ten years, whichever is greater. Attach additional signed sheets if necessary. Also list and explain any period(s) of unemployment. Please answer all inquiries. “See Resume” is not acceptable.

Employer's Name

Phone

Address

Supervisor (name and title)

Job Title

Starting Salary

Ending Salary

Duties and Responsibilities

From (month and year)

To (month and year)

Reason for Leaving

May we contact your employer

Yes

Employer's Name

Phone

Address

Supervisor (name and title)

Job Title

Starting Salary

Ending Salary

Duties and Responsibilities

From (month and year)

To (month and year)

Reason for Leaving

May we contact your employer

Yes

Employer's Name

Phone

Address

Supervisor (name and title)

Job Title

Starting Salary

Ending Salary

Duties and Responsibilities

From (month and year)

To (month and year)

Reason for Leaving

May we contact your employer

Yes

Employer's Name

Phone

Address

Supervisor (name and title)

Job Title

Starting Salary

Ending Salary

Duties and Responsibilities

From (month and year)

To (month and year)

Reason for Leaving

May we contact your employer

Yes

Military

Details

Branch

Position/Rank

Date of Service from:

Date of Service to:

Describe any education, training, and duties that relate to the position you are applying for.

Reserve Status

Education

High School / GED

School

Location

Diploma/Degree Received

Business School

School

Location

Diploma/Degree Received

College / University

School

Location

Diploma/Degree Received

Trade / Vocational School

School

Location

Diploma/Degree Received

Please list special skills, experience and/or training that relate to the position you are applying for:

Professional Licenses, Registrations, and/or Certifications

List all licenses and certifications you have had or now hold, including any national certifications, as well as the State they are held in. Please include the expiration dates.

Professional Licenses, Registrations, and/or Certifications

Record of Conviction

Have you ever been convicted or entered a guilty or nolo contendere plea of a felony?

Yes

If yes, please explain and provide the name, nature of offense, and date of conviction.

Have you ever been convicted or entered a guilty or nolo contendere plea of a misdemeanor?

Yes

If yes, please explain and provide the name, nature of offense, and date of conviction.

Do you have any felony or criminal charges pending against you?

Yes

If yes, please explain and provide the name, nature of offense, and date of arraignment.

References

Give the name, address and telephone numbers of three references who are not related to you:

Consent

Certification

I have read and consent to the statements below:

Upon a conditional offer of employment, I understand that I may be required to submit to a criminal background check, including submission of my fingerprints and hereby authorize the State of Michigan department of police, licensing and regulatory department, or any other prescribed vendor to obtain my criminal history record. I understand that if I am offered employment, I may be required and agree to submit to a physical examination, as well as any urine screen for alcohol and drug analysis. I understand that any offer of employment by Bay County Medical Care Facility is contingent upon the results of any criminal background check, employment or education verification, alcohol and drug screen, and physical examination.

I have read and fully understand the questions on this application for employment. I have completely, truthfully, and accurately answered each and every question to the best of my knowledge. I understand that all the inquiries on this application are subject to verification and authorize any schools that I have attended, licensing and certification boards and current and previous employers to release any requested information to the Facility. I also specifically waive written notice from any and all former employers regarding their disclosure to the Facility of any prior disciplinary action and waive any claim against the Facility and current or former employers arising from such investigation or disclosure. I understand that any misrepresentation of the information I have supplied or failed to supply can result in a rejection of this application or if I have been hired, an immediate dismissal at the sole discretion of the Facility.

I understand and agree that in the absence of an express written contract or agreement to the contrary, signed by an authorized representative of the Facility and by me or my authorized representative, any employment I accept shall be for an indefinite term and may be terminated at any time with or without cause either by me or at the will and sole discretion of the Facility regardless of any contrary provisions in any other forms, manuals, handbooks or other documents. Similarly, such employment shall be at the wages, benefits, hours and conditions as the Facility may determine and change from time to time and I agree to abide by any rules, regulations, policies and procedures that may be established from time to time. I understand that no one, other than an authorized representative of the Facility has any authority to enter into an agreement with me contrary to the provisions of this paragraph and that any such agreement must be in writing and signed by such authorized representative or it shall not be effective.

It is with full understanding and agreement with the provisions of this Certification that I will accept any employment offered to me.

Michigan law requires that a person with a disability requiring an accommodation for employment must notify the employer, in writing, within 182 days after the need is known.

Signature of Applicant

Date

MM slash DD slash YYYY

Application For Employment