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APPLICATION FOR EMPLOYMENT
BAY COUNTY MEDICAL CARE FACILITY
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
*
Indicates required field
Position Applied For
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Please make selection
CNA
LPN
RN
Last Name
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Middle Initial
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First Name
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Home Phone Number
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Mobile Phone Number
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Email
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What prompted your application
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Have you ever filed an application with us before?
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Yes
No
If Yes, what position did you apply for?
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If Yes, when
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Have you ever been employed by the Bay County Medical Care Facility?
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Yes
No
If Yes, please state dates of employment
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If Yes, reason for leaving
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Salary Expectation (Enter $ amount or "Negotiable")
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Per
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Hour
Week
Year
Date available for work
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Are you available for the following? (Check all that apply)
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Full Time
Part Time
Per Diem
Indicate any previous names or nicknames to verify information in this application
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Are you related to or know anyone who works for Bay County Medical Care Facility?
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Yes
No
If Yes, please name individual(s)
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Are you willing to work any of the following? (Check all that apply)
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Variable Shifts
Rotating Shifts
Weekends
Specify any dates/times you are unavailable for work
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Do you have any responsibilities other than work that may interfere with our job requirements?
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Yes
No
If Yes, explain
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Do you have a reliable form of transportation to get to work?
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Yes
No
Are you 18 yrs of age or older?
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Yes
No
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?
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Yes
No
Are you currently on "layoff" status and subject to recall?
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Yes
No
Have you ever been discharged by an employer or resigned in lieu of discharge?
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Yes
No
Have you ever been disciplined for violations of company policy?
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Yes
No
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.
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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
Employer's Name
*
Employer's Phone Number
*
Supervisor (Name & Title)
*
Employer's Address
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Line 1
Line 2
City
State
Zip Code
Country
Starting Salary $
*
From (month & year)
*
Ending Salary $
*
To (month & year)
*
Duties and Responsibilities
*
Reason for Leaving
*
May we contact this employer?
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Yes
No
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
Employer's Name
*
Employer's Phone Number
*
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
*
May we contact this employer?
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Yes
No
MILITARY
Have you ever served in the military?
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Yes
No
If Yes, Position/Rank
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Service Date From
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Service Date To
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Describe any education, training, and duties that relate to the position you are applying for
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Branch?
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Did not serve
Army
Air Force
Navy
Marine Corps
Coast Guard
Served in military of foreign country
Reserve Status
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EDUCATION
Name of School (High School / GED)
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Name of School (Business School)
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City & State of School
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City & State of School
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Diploma/Degree Received
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Diploma/Degree Received
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Name of School (College/University)
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City & State of School
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Diploma/Degree Received
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Name of School (Trade/Vocational)
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City & State of School
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Diploma/Degree/Certificate Received
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Please list special skills, experience and/or training that relate to the position you are applying for:
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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?
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Yes
No
Have you ever been denied a license or certification?
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Yes
No
If you answered yes to any of the above questions, explain in detail on an attached signed statement.
*
RECORD OF CONVICTION
Have you ever been convicted or entered a guilty or nolo contender plea of a felony?
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Yes
No
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 contender plea of a misdemeanor?
*
Yes
No
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?
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Yes
No
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
Name
*
First
Last
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Name
*
First
Last
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
Name
*
First
Last
Phone Number
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
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.
Please enter your initials
*
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.
Please enter your initials
*
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.
Please enter your initials
*
If you need to explain or detail any response.
*
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.
Please type your full name as Signature of Applicant
*
Date (mm/dd/yyyy)
*
Attach Cover Sheet
*
Max file size: 20MB
Attach Resume'
*
Max file size: 20MB
Submit
Home
Departments
Activity Dept
Admissions Dept
Business Office Dept
Dietary Dept
Discharge Planning Dept
Environmental Services Dept
Human Resources Dept
Nursing Dept
In-Service/Infection Control Dept
Rehab Therapy Dept
Restorative Dept
Social Service Dept
Directions
Employment
How to apply
Open Positions
About
Facility
Staff
Medical Services
Contact Us
History
Administration
DHHS Board