Apply for a Position - Ingham County Medical Care Facility on Dobie Road

Position Applying For*

Have you ever filed an application or been employed with us before?*

Yes
No

When?*

Date Started

Date Left

What Department?

What Position?

Reason for Leaving

Personal Information

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Home Phone*

Cell Phone

Birth Date*

Drivers License #*

Days or times NOT available for work

Shifts Willing To Work*

1st
2nd
3rd

Salary Expectation*

Date Available To Start*

Desired Employment Status*

Full-Time
Part-Time
Special Part-time

U.S. Citizen?*

Yes
No

Do you have a legal right to remain in the United States permanently?*

Yes
No

If employed, can you submit verification of your legal right to remain in the United States?*

Yes
No

Do you have a reliable form of transportation available to you to go to and from work?*

Yes
No

What prompted you to apply?*

Upload your Cover Letter/Resume

How did you learn about the particular position for which you are applying?

Are you a current or former member of the United States Military?*

Yes
No

Military Information

Service*

Branch*

Served From*

Served To*

Were you honorably discharged?*

Yes
No

Reserve Status*

Describe any specialized training and/or duties

Employment Information

List your last four employers or all employers for the last ten years, whichever is greater. "See Resume" is not acceptable.

Employer

Employer Name

Position

Employed From

Employed To

Duties/Responsibilities

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone

May we contact this employer?

Yes
No

Supervisor Name

First Last

Supervisor Title

Reason for Leaving

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

Yes
No

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

Yes
No

Have you ever been disciplined (other than discharged) by an employer?*

Yes
No

Explain all such incidents including facts, dates, describing any actions you took, and any resolution.

How much time have you missed from work or school in the past twelve months?

If the job requires that you be able to operate a motor vehicle, do you have a valid driver's license?*

Yes
No

Education

High School(s)

High School Name

High School Location

Degree(s)

Business School

Business School Name

Business School Location

Degree(s)

College/University

College/University Name

College/University Location

Degree(s)

Trade/Vocational School

Trade/Vocational School Name

Trade/Vocational School Location

Degree(s)

Extracurricular activities & honors received in school

Professional Licenses, Registrations, and/or Certifications

List all states in which you are or have been licensed or certified and any national affiliations.

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

Yes
No

Have you ever been denied a license or certification?*

Yes
No

If yes to either, please explain.*

Criminal History

Do you have any felony and/or misdemeanor charges pending against you?*

Yes
No

Have you ever been convicted of or pleaded guilty to any crime?*

Yes
No

If yes to either, explain by giving the date, nature of the offense, and circumstances involved*

Are you 18 years of age or older?*

Yes
No

Are you able to perform the essential duties of the job for which you have applied with or without a reasonable accommodation?*

Yes
No

References

Please give the name, address, and phone number of three references who are not related to you.

References

Reference Name

First Last

Reference Phone Number

Reference Address

Street Address Address Line 2 City State ZIP Code

Certification

Certification*

I certify that the information contained in this application is correct. I authorize the references listed above and designated former and/or current employer(s) to give you any and all information concerning my previous or current employment and any pertinent information that they may have, personal or otherwise.

I understand that I may be required to submit to a physical examination, which may include a drug test, prior to beginning employment and that I must satisfactorily pass such an examination to obtain employment.

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 designated current and previous employers to release any requested information to the Ingham County Medical Care Facility (“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 or falsification 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 Ingham County Medical Care Facility.

I understand and agree that in the absence of an express written contract or agreement to the contrary, signed by an authorized executive of the Ingham County Medical Care Facility (“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 executive 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 executive or it shall not be effective.

I agree that any action or suit against the “facility”(employer) arising out of my employment or termination of employment, including but not limited to claims arising under State or Federal civil rights statues, must be brought within 180 days of the event giving rise to the claims to be forever barred. I waive any limitation periods to the contrary.

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

I agree to the Terms of Service

Identification Verification SSN*

Please list the last 4 digits of your social security number.

Today's Date*

MM

DD

YYYY

Signature of Applicant*

Comments

This field is for validation purposes and should be left unchanged.

Team Dobie Application

Personal Information

Military Information

Employment Information

Employer

Education

High School(s)

Business School

College/University

Trade/Vocational School

Professional Licenses, Registrations, and/or Certifications

Criminal History

References

References

Certification