Employment Application Position Applying For*Have you ever filed an application or been employed with us before?*YesNoWhen?* Date Started Date Left What Department?What Position?Reason for LeavingPersonal InformationName* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Home Phone*Cell PhoneBirth Date* Drivers License #*Days or times NOT available for workShifts 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?*YesNoDo you have a legal right to remain in the United States permanently?*YesNoIf employed, can you submit verification of your legal right to remain in the United States?*YesNoDo you have a reliable form of transportation available to you to go to and from work?*YesNoWhat prompted you to apply?*Upload your ResumeAccepted file types: txt, pdf, doc, docx, rtf, ppt, pptx.How did you learn about the particular position for which you are applying?NewspaperEmployment OfficeSchool or College Counselor or Other OfficialFriend or Relative Not Working for the FacilityFriend or Relative Working for the FacilityState or Federal AgencyAre you a current or former member of the United States Military?*YesNoMilitary InformationService*Branch*Served From* Served To* Were you honorably discharged?*YesNoReserve Status*Describe any specialized training and/or dutiesEmployment InformationList your last four employers or all employers for the last ten years, whichever is greater. "See Resume" is not acceptable.Employer NamePositionEmployed From Employed To Duties/ResponsibilitiesEmployer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Employer PhoneMay we contact this employer?YesNoSupervisor Name First Last Supervisor TitleReason for Leaving Are you currently on "layoff" status and subject to recall?*YesNoHave you ever been discharged by an employer or resigned in lieu of discharge?*YesNoHave you ever been disciplined (other than discharged) by an employer?*YesNoExplain 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?*YesNoEducationHigh School(s)High School NameHigh School LocationDegree(s) Business SchoolBusiness School NameBusiness School LocationDegree(s) College/UniversityCollege/University NameCollege/University LocationDegree(s) Trade/Vocational SchoolTrade/Vocational School NameTrade/Vocational School LocationDegree(s) Extracurricular activities & honors received in schoolProfessional Licenses, Registrations, and/or CertificationsList 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?*YesNoHave you ever been denied a license or certification?*YesNoIf yes to either, please explain.*Criminal HistoryDo you have any felony and/or misdemeanor charges pending against you?*YesNoHave you ever been convicted of or pleaded guilty to any crime?*YesNoIf yes to either, explain by giving the date, nature of the offense, and circumstances involved*Are you 18 years of age or older?*YesNoAre you able to perform the essential duties of the job for which you have applied with or without a reasonable accommodation?*YesNoReferencesPlease give the name, address, and phone number of three references who are not related to you.Reference Name First Last Reference Phone NumberReference Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CertificationCertification*You must read the entire certification prior to agreeing to the Terms of ServiceI certify that the information contained in this application is correct. I authorized the references listed above and designated former and/or current employer(s) to give you and 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 facility. I understand 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 again the "facility" arising out of my employment or termination of employment, including, but not limited to, claims arising under State or Federal civil rights statutes, 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*NameThis field is for validation purposes and should be left unchanged.