IONIA COUNTY MEMORIAL HOSPITAL

IONIA COUNTY MEMORIAL HOSPITAL

Application for Employment

Equal access to programs, services, and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Personnel Department.

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Please Print

Position(s) applied for ______________________________ Date of Application _______________

___________________________________________________

Referral Source □ Advertisement □ Employee □ Relative □ Government Employment Agency

□ Walk-in □ Private Employment Agency □ Other ______________

Name of source (if applicable) ______________________________________

Name ______________________________________________________________________________

Last First Middle

Address _____________________________________________________________________________

Street City State Zip

Social Security # ____________________ E-Mail Address ___________________________________

Telephone ( ) _____________________ Cell /Beeper /Other (____)__________________________

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If necessary, best time to call you at home is ………………………………………….._ __:_ __am / pm

May we contact you at work? □ Yes □ No

If, yes work number and best time to call ………….…(____)________________ _ __:_ __am / pm

If you are under 18 and it is required, can you furnish a work permit? □ Yes □ No

If no, please explain ____________________________________________________________

Have you submitted an application here before? □ Yes □ No

If yes, give approx. date(s) and position(s) ___________________________________________

______________________________________________________________________________

Have you ever been employed here before? □ Yes □ No

If yes, give dates _________________________ From _______________To__________________

Are you legally eligible for employment in this country? □ Yes □ No

Dates available for work ___________________ What is your desired salary range? ______________

Type of employment desired □Full-Time □Part-Time □Temporary □Seasonal □ Educational Co-Op

Will you relocate if job requires it? □ Yes □ No Will you travel if job requires it? □ Yes □ No

Are you able to meet attendance requirements of the position? □ Yes □ No

Will you work overtime if required? □ Yes □ No

If no, please explain __________________________________________________________________

Have you ever been bonded? □ Yes □ No

Have you ever pled “guilty” or “no contest”, or been convicted of a crime? □ Yes □ No

If yes, please provide date(s) and details _________________________________________________

__________________________________________________________________________________

Answering yes to these questions does not constitute an automatic bar to employment. Factors such as date of the offense, seriousness and nature of the violation, rehabilitation and position applied for will be taken into account.

Driver’s license number if driving is an essential job function _____________________ State ________

Employment History

Provide the following information of your past and current employers, assignments, or volunteer activities; starting with the most recent (use additional sheets if necessary). Explain any gaps in employment in comments section below.

Employer Telephone	Dates Employed From	Dates Employed To	Summarize the Type of Work Performed and Job Responsibilities
Address
Starting Job Title / Final Job Title	Hourly Rate Starting	Hourly Rate Ending
Immediate Supervisor and Title
Reason for leaving
May we contact for references?	Yes	No

Employer Telephone	Dates Employed From	Dates Employed To	Summarize the Type of Work Performed and Job Responsibilities
Address
Starting Job Title / Final Job Title	Hourly Rate Starting	Hourly Rate Ending
Immediate Supervisor and Title
Reason for leaving
May we contact for references?	Yes	No

Employer Telephone	Dates Employed From	Dates Employed To	Summarize the Type of Work Performed and Job Responsibilities
Address
Starting Job Title / Final Job Title	Hourly Rate Starting	Hourly Rate Ending
Immediate Supervisor and Title
Reason for leaving
May we contact for references?	Yes	No

Comments (Including explanation for gaps in employment)

____________________________________________________________________________________

Skills and Qualifications

Summarize any special training, licenses and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying.

_______________________________________________________________________________________________

________________________________________________________________________________________________

Educational Background (if job related)

A . List three schools attended starting with the most recent. B. List number of years completed. C. Indicate degree or diploma earned, if any. D. Grade point average or Class Rank. E. Major Field of study F. Minor Field of study.

A. SCHOOL	B. NUMBER OF YEARS COMPLETED	C. DEGREE / DIPLOMA	D. GPA / CLASS RANK	E. MAJOR	F. MINOR

References

List name and telephone number of three business/work references that are NOT related to you and are NOT previous supervisors. If not applicable, list three school or personal references that are not related to you.

Name of Reference	Telephone # (include area code)	Number of Years Known

Additional Information

List professional, trade, business, or civic associations and any office held.

Exclude memberships that would reveal race, color, religion, sex, national origin, citizenship, age, mental or physical disabilities, veteran/reserve/National Guard or any other similarly protected states.

Organization/Association Name	Offices Held

List special accomplishments, publications, awards, etc.

_______________________________________________________________________________

List any additional information you would like us to consider.

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Applicant Statement

I certify that all information I have provided in order to apply for and secure work with Ionia County Memorial Hospital is true, complete, and correct.

I am not currently excluded from providing services to any governmental program nor am I the subject of an investigation which has potential to lead to my exclusion.

I understand that any information provided by me that is found to be false, incomplete or misrepresented in any respect, will be sufficient cause to (1) cancel further consideration of this application, or (2) immediately discharge me from Ionia County Memorial Hospital’s services, whenever it is discovered.

I expressly authorize, without reservation, Ionia County Memorial Hospital, its representatives, employees or agents to contact and obtain information from all references (personal and professional), employers, public agencies, licensing authorities and educational institutions and to otherwise verify the accuracy of all information provided by me in this application, resume or job interview.

I hereby waive any and all rights and claims I may have regarding Ionia County Memorial Hospital, its agents, employees or representatives, for seeking, gathering, and using such information in the employment process and all other persons, corporations or such organizations for furnishing such information about me.

I understand that Ionia County Memorial Hospital does not unlawfully discriminate in employment and no question on this application is used for the purpose of limiting or excusing any applicant from consideration for employment on a basis prohibited by applicable local, state or federal law.

I understand that this application remains current for only 30 days. At the conclusion of that time, if I have not heard from Ionia County Memorial Hospital and still wish to be considered for employment, it will be necessary to reapply and fill out a new application.

If I am hired, I understand that unless I am covered under a union contract, I am an At Will employee. I am free to resign at any time, with or without cause and without prior notice, and Ionia County Memorial Hospital reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law.

I also understand that this application does not constitute an agreement or contract for employment for any specified period or definite duration. I understand that no supervisor or representative of Ionia County Memorial Hospital is authorized to make any assurances to the contrary and that no implied oral or written agreements contrary to the foregoing express language are valid unless they are in writing and signed by Ionia County Memorial Hospital’s Chief Executive Officer.

I also understand that if I am hired, I will be required to provide proof of identity and legal authority to work in the United States and that federal immigration laws require me to complete an I-9 Form in this regard.

DO NOT SIGN UNTIL YOU HAVE READ THE ABOVE APPLICANT STATEMENT

I certify that I have read, fully understand and accept all terms of the foregoing Applicant Statement.

Signature of Applicant ______________________________ Date __________________