Application

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.

NOTE - Red asterisks * denote required fields that need to be filled out before form can be submitted

PERSONAL INFORMATION

Are you legally eligibile for employement in the United States? *

Yes No

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

Yes No

EMPLOYMENT HISTORY

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

Employer 1

Supervisor (Name & Title) *

Employer's Address *

Line 1

Line 2

City

State

Zip Code

Country

Starting Salary $ *

From (month & year) *

Ending Salary $ *

To (month & year) *

Duties and Responsibilities *

Employer 2

Employer's Name *

Supervisor (Name & Title) *

Employer's Address *

Line 1

Line 2

City

State

Zip Code

Country

Starting Salary $ *

From (month & year) *

Ending Salary $ *

To (month & year) *

Reason for Leaving *

May we contact this employer? *

Yes No

Employer's Phone Number *

Duties and Responsibilities *

Employer 3

Supervisor (Name & Title) *

Employer's Address *

Line 1

Line 2

City

State

Zip Code

Country

Starting Salary $ *

From (month & year) *

Ending Salary $ *

To (month & year) *

Reason for Leaving *

May we contact this employer? *

Yes No

Duties and Responsibilities *

Employer 4

Employer's Name *

Supervisor (Name & Title) *

Employer's Address *

Line 1

Line 2

City

State

Zip Code

Country

Starting Salary $ *

From (month & year) *

Ending Salary $ *

To (month & year) *

Reason for Leaving *

Employer's Phone Number *

Duties and Responsibilities *

MILITARY

Have you ever served in the military? *

Yes No

If Yes, Position/Rank *

Service Date From *

Service Date To *

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

Reserve Status *

EDUCATION

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. *

Have you ever had any professional license or certification placed under investigation, disciplined, suspended, revoked or put on probation, including current license and certifications? *

Yes No

Have you ever been denied a license or certification? *

Yes No

RECORD OF CONVICTION

REFERENCES

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

CERTIFICATION

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.

APPLICATION FOR EMPLOYMENT
BAY COUNTY MEDICAL CARE FACILITY

PERSONAL INFORMATION

EMPLOYMENT HISTORY

Employer 1

Employer 2

Employer 3

Employer 4

MILITARY

EDUCATION

PROFESSIONAL LICENSES, REGISTRATIONS, AND/OR CERTIFICATIONS

RECORD OF CONVICTION

REFERENCES

CERTIFICATION

Hours

Telephone

APPLICATION FOR EMPLOYMENT BAY COUNTY MEDICAL CARE FACILITY

PERSONAL INFORMATION

EMPLOYMENT HISTORY

Employer 1

Employer 2

Employer 3

Employer 4

MILITARY

EDUCATION

PROFESSIONAL LICENSES, REGISTRATIONS, AND/OR CERTIFICATIONS

RECORD OF CONVICTION

REFERENCES

CERTIFICATION

Hours

Telephone

APPLICATION FOR EMPLOYMENT
BAY COUNTY MEDICAL CARE FACILITY