Employment Application

Employment Application_2018

EMPLOYMENT APPLICATION

MARLETTE REGIONAL HOSPITAL EMPLOYMENT APPLICATION

* Required Field

PERSONAL INFORMATION

* First Name, Middle Initial, Last Name:

Other Names Used:

* Address:

* City, State, Zip Code:

* E-mail Address:

* Phone:

Alternate Phone:

* Are you over the age of 18?
Yes
No
* Are you legally eligible to work in the United States?
Yes
No

If you are not a United States citizen, please list type of visa and expiration date.

Visa type, visa expiration date (mm/yyyy):

* Have you used illegal drugs or controlled substances without a prescription in the last two years?

Yes
No

If yes, please explain:

* Have you ever been convicted of a misdemeanor or felony offense? (A conviction of crime will not necessarily be a bar to employment. Factors such as age at the time of the offense, remoteness of the offense, type of offense, and rehabilitation will be taken into account in determining effect of suitability for employment).

Yes
No

If yes, please explain:

* Are you currently excluded, or are you aware of any potential exclusion from participation in Federally-funded health care programs including Medicare and Medicaid?
Yes
No

If yes, please explain:

* Have you ever applied at Marlette Regional Hospital?

Yes
No

If yes, when and what position?

* Are you currently or ever been employed by Marlette Regional Hospital or affiliates?

Yes
No

If yes, when and what department?

* Are you related to any team member or board member of Marlette Regional Hospital or affiliates?

Yes
No

Relation’s Name:

POSITION APPLIED FOR

Position Name:

Position Department:

Check all that apply:
Status:
Full Time | Part Time | Casual/Relief/Contingent
Shift:
Days | Afternoons | Nights
Availability:
Monday | Tuesday | Wednesday | Thursday | Friday | Saturday | Sunday

EDUCATION AND TRAINING

High School or Equivalent:

* School Name:


* Diploma or Degree Attained:

College:

School Name:


Diploma or Degree Attained:

Add College

College #2:

School Name:


Diploma or Degree Attained:

Add College

College #3:

School Name:


Diploma or Degree Attained:

Add Vocational School

Technical or Vocational School:

School Name:


Diploma or Degree Attained:

Add Vocational School

Technical or Vocational School #2:

School Name:


Diploma or Degree Attained:

Add Post-Graduate or Other Training

Post-Graduate or Other Training:

School Name:


Diploma or Degree Attained:

Add Post-Graduate or Other Training

Post-Graduate or Other Training #2:

School Name:


Diploma or Degree Attained:

Specialized Skills

Specialized Skills:

Specialized Skills (including medical terminology) Obtained:


PROFESSIONAL LICENSES, REGISTRATIONS AND/OR CERTIFICATIONS

Add License/Registration/Certification

License/Registration/Certification:

Type of License:


License/Registration/Certification Number:


State Where Issued:


Original Date Received:


Expiration Date:


Add License/Registration/Certification

License/Registration/Certification #2:

Type of License:


License/Registration/Certification Number:


State Where Issued:


Original Date Received:


Expiration Date:


Add License/Registration/Certification

License/Registration/Certification #3:

Type of License:


License/Registration/Certification Number:


State Where Issued:


Original Date Received:


Expiration Date:


PROFESSIONAL MEMBERSHIPS/ORGANIZATIONS

Name(s) of Professional Memberships/Organizations:

EMPLOYMENT RECORD

List each employer, beginning with the most recent. Please complete all fields to the best of your knowledge.

Employer #1

Company Name (most recent position):


Address:


City, State, Zip:


Job Title:


Date Employed:

From (mm/yyyy):


To (mm/yyyy):


Average Hours Worked per Week:


Rate of Pay:


Describe Responsibilities:

Reason for Leaving:


Manager/Supervisor Name:


Manager/Supervisor Phone Number:


Manager/Supervisor E-mail Address:


May we contact your Manager/Supervisor?

Yes
No
If no, please explain:

Employer #2

Company Name (second most recent position):


Address:


City, State, Zip:


Job Title:


Date Employed:

From (mm/yyyy):


To (mm/yyyy):


Average Hours Worked per Week:


Rate of Pay:


Describe Responsibilities:

Reason for Leaving:


Manager/Supervisor Name:


Manager/Supervisor Phone Number:


Manager/Supervisor E-mail Address:


May we contact your Manager/Supervisor?

Yes
No
If no, please explain:

Employer #3

Company Name (third most recent position):


Address:


City, State, Zip:


Job Title:


Date Employed:

From (mm/yyyy):


To (mm/yyyy):


Average Hours Worked per Week:


Rate of Pay:


Describe Responsibilities:

Reason for Leaving:


Manager/Supervisor Name:


Manager/Supervisor Phone Number:


Manager/Supervisor E-mail Address:


May we contact your Manager/Supervisor?

Yes
No
If no, please explain:

Employer #4

Company Name (fourth most recent position):


Address:


City, State, Zip:


Job Title:


Date Employed:

From (mm/yyyy):


To (mm/yyyy):


Average Hours Worked per Week:


Rate of Pay:


Describe Responsibilities:

Reason for Leaving:


Manager/Supervisor Name:


Manager/Supervisor Phone Number:


Manager/Supervisor E-mail Address:


May we contact your Manager/Supervisor?

Yes
No
If no, please explain:

Employer #5

Company Name (fifth most recent position):


Address:


City, State, Zip:


Job Title:


Date Employed:

From (mm/yyyy):


To (mm/yyyy):


Average Hours Worked per Week:


Rate of Pay:


Describe Responsibilities:

Reason for Leaving:


Manager/Supervisor Name:


Manager/Supervisor Phone Number:


Manager/Supervisor E-mail Address:


May we contact your Manager/Supervisor?

Yes
No
If no, please explain:

REFERRAL INFORMATION

Marlette Regional Hospital Website
Marlette Regional Hospital Employee

Name:


Social Media

Source:


Other Website/Job Board

Source:


Printed Advertising

Source:


Radio Ad

Source:


Other

Source:


REFERENCES

List three professional references (supervisors, co-workers, and/or instructors, who are familiar with the quality of your work, and have known you at least two years).


Reference #1:

* Name:


Position/Title:


* Phone Number:


E-mail Address:


Reference #2:

* Name:


Position/Title:


* Phone Number:


E-mail Address:


Reference #3:

* Name:


Position/Title:


* Phone Number:


E-mail Address:



* I have read (click here) and agree to uphold the MRH WE CARE Service Excellence Standards at all times should I be selected for employment.

ATTESTATION

I certify that the information I have provided on this application is true and complete to the best of my knowledge, and that I have not knowingly withheld any fact or circumstances which would, if disclosed, affect my application. I fully understand that the misrepresentation or omission of facts or circumstances will be sufficient cause for rejection of my application if Marlette Regional Hospital has not employed me and for immediate dismissal if Marlette Regional Hospital has employed me.


I grant permission to Marlette Regional Hospital’s employment representatives to contact any of the employers, supervisors, managers, educational institutions, and/or references listed in this application unless I have indicated to the contrary in the appropriate fields on this application. I authorize my former and/or current employer(s) to release information pertaining to my work record, work habits, and my work performance while in their employ. I understand that Marlette Regional Hospital may and hereby authorize it to solicit information regarding my character, criminal background record, driving record, previous employment, and/or similar background information pertaining to the position for which I am applying and hereby release all individuals and organizations from any liability or damages which may result from furnishing such information. I waive any right, under Public Act 397 of 1978, to receive written notice from this hospital or former employers that such information has been released.


I understand that should an employment offer be extended to me and accepted that I will fully adhere to the policies, rules and regulations of employment of the employer. I further understand that the policies, rules, regulations of employment, this application, anything said during the interview process, or any verbal offer of employment shall not be deemed to constitute the terms of an implied employment contract. I understand that employment with Marlette Regional Hospital is contingent upon proof of identity of verification of eligibility of employment in the United States, in accordance with the Immigration Reform Act of 1986. I have read and understand the above, and hereby certify that the facts I have provided in my employment application are true and complete. Submitting my application constitutes my signature and desire to apply for employment.


Marlette Regional Hospital provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, disability, genetic information, marital status, amnesty, or status as a covered veteran in accordance with applicable federal, state, and local laws. Marlette Regional Hospital complies with applicable laws governing non-discrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including, but not limited to, hiring, placement, promotion, termination, layoff, recall, transfer, leave of absence, compensation, and training.

* I agree to the above attestation.