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Woodland Haven /
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Application for Employment

The Houghton County Medical Care Facility is an equal opportunity employer and does not discriminate in employment due to race, color, religion, sex, age, national origin, handicap, marital status, familial status, genetic information, veteran status, or any other legally protected activity or status.

Applications will be complete if all questions are answered. The failure to respond to an inquiry or the inclusion of information not requested may disqualify your application from consideration.

Conditions of employment are stated at the end of the Employment Application. Please read them carefully before you sign/submit this application.

Click here for a PDF version of the application that can be printed.

 

 

  PERSONAL    
       

Last Name


First Name


Middle Initial


 

Alias/Alternate Names
Please provide any aliases or alternate names
needed to verify the information contained in this
application, including verifying your education and
work history.

 

Present Address (Street, City, State, Zip)


How many years have you lived at present address?


Phone

Previous Address (Street, City, State, Zip)


How long did you live there?



 

Job(s) Applied for:

   

Job 1


Rate of pay expected


Pay Rate Per (ie hour, year)


Job 2


Rate of pay expected


Pay Rate Per (ie hour, year)


 

How did you learn of this opening?

Do you want to work full-time or part-time?

Shift(s) preference:

 

Are you 18 years or older?

Yes
No
   
 

Have you worked for us before?

If yes, when?

 
 

List any relatives working for us:

   
 

If hired, on what date would you be available to start work?

   

 

Professional Licenses and/or certifications.

Include Type, Organization or State Issue, Number, Date Expires for each.

If hired, do you have reliable means of transportation to get to work?




Are you able to perform the essential functions of the job for which you are applying with or without reasonable accommodation?

Yes
No

If yes, describe and/or explain your work limitations.



Are you subject to a layoff or recall?

Yes
No

If you are under 18 years old, can you provide a work permit?

Yes
No

Are you legally eligible for employment in the United States?

Yes
No
       
 

Houghton County Medical Care Facility is required to conduct a criminal history background check on all applicants receiving a good faith offer of employment. Upon a good faith offer of employment, you will be requested to disclose any felony or misdemeanors that may statutorily disqualify you from employment with Houghton County Medical Care Facility, including, but not limited to, any conviction, guilty plea, or no contest plea of any felony or attempt or conspiracy to commit any felony, a crime involving patient abuse, health care fraud, and any crimes related to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance, or any misdemeanor involving: abuse; neglect; torture; cruelty; assault without a firearm or dangerous weapon; use of a firearm or dangerous weapon with intent to injure; criminal sexual conduct; home invasion; embezzlement, larceny; fraud; second or third degree retail fraud; negligent homicide; the possession, use, or delivery of a controlled substance; or the creation, delivery, or possession with intent to manufacture or deliver a controlled substance.

Have you ever been convicted, including a plea of guilty or no contest of a felony or misdemeanor crime, excluding sealed or expunged convictions?

Yes
No

Do you have any felony charges or misdemeanor charges that would statutorily disqualify you from employment pending against you?

Yes
No

If you answered "yes" to any of the above questions in this section, indicate each offense for which you were convicted and the year of the conviction. If you were arrested but not convicted, indicate the charge, the year of the charge and how the charge was resolved or if it is still pending. Note: A criminal record does not necessarily disqualify an applicant for employment, but will be considered with all other information to determine whether you will be hired, including but not limited to the nature of the crime, the time elapsed since conviction, the duties you may be assigned, and any statutory exclusion. Dishonesty about a criminal record will disqualify you.

       
  EDUCATIONAL BACKGROUND  



 

HIGH SCHOOL

Include Type of School, Name and Address, Years Attended, Graduated (Yes or No), Course or Major

 

COLLEGE

Include Type of School, Name and Address, Years Attended, Graduated (Yes or No), Course or Major

 

POST GRADUATE

Include Type of School, Name and Address, Years Attended, Graduated (Yes or No), Course or Major

 

BUSINESS or TRADE

Include Type of School, Name and Address, Years Attended, Graduated (Yes or No), Course or Major

 

OTHER

Include Type of School, Name and Address, Years Attended, Graduated (Yes or No), Course or Major



       
  MILITARY SERVICE RECORD  
       

Have you ever served in the armed forces?


Yes
No

Date of Duty Start (Month, Day, Year)


Date of Duty End (Month, Day, Year)

Rank At Discharge

Type of Discharge



 

Describe your military duties if you feel they will benefit you for the applied job.

Reserve Status

 
       
  PERSONAL REFERENCES

Provide three work, school or other references you are not related to you.

 
       

 

Personal Reference 1:

Include Name, Occupation, Address, Phone Number.

 

Personal Reference 2:

Include Name, Occupation, Address, Phone Number.

 

Personal Reference 3:

Include Name, Occupation, Address, Phone Number.



       
  PRIOR WORK HISTORY  
       

1.

Start Date


End Date


Employer Name, Address, Phone Number


Rate of Pay Start


Rate of Pay Finish


Supervisor's Name and Title


Reason for Leaving


Describe the work you did.



2.

Start Date


End Date


Employer Name, Address, Phone Number


Rate of Pay Start


Rate of Pay Finish


Supervisor's Name and Title


Reason for Leaving


Describe the work you did.


3.

Start Date


End Date


Employer Name, Address, Phone Number


Rate of Pay Start


Rate of Pay Finish


Supervisor's Name and Title


Reason for Leaving


Describe the work you did.


4.

Start Date


End Date


Employer Name, Address, Phone Number


Rate of Pay Start


Rate of Pay Finish


Supervisor's Name and Title


Reason for Leaving


Describe the work you did.

       

May we contact the employers listed above?

If not, indicate below which one(s) your do not want us to contact.

 

Occasionally the form of an application makes it difficult for all individual to adequately summarize his/her complete
work/experience background. To assist us in finding the proper position for you in our facility, use the space below to summarize any
additional information necessary to describe your full qualifications. Completion of this section is voluntary.

Thank you for completing this application form and for your interest in employment with us. We would like to assure you that your
opportunity for employment with this company will be based only on your merit and on no other consideration.

HOUGHTON COUNTY MEDICAL CARE FACILITY
1100 W. QUINCY STREET, HANCOCK, MICHIGAN 49930

PLEASE READ CAREFULLY
APPLICANT'S CERTIFICATION AND AGREEMENT

       

I understand and agree that all statements and information made in connection with this application, and any accompanying
resume or document, are true and complete, and that I have not knowingly withheld any information or circumstances which
would affect my application unfavorably. I fully understand that the falsification, misrepresentation, or omission of any statement
or information provided in this application or accompanying resume, document, or information will be sufficient cause for the
cancelation of my consideration for employment or may be the cause for dismissal if I have been employed.

Initial

       

I authorize the verification and investigation of all statements contained in this application, including a criminal background check
as defined by the Facility Policy in accordance with the Michigan Public Act 27 and 28 of 2006, or any information required to
determine my qualifications for the position for which I am applying, including my education, work, and professional history.
I request that my previous employers contacted by the Facility in connection with this application fully respond to all inquiries
concerning my previous employment. I specifically waive prior written notice of disclosure of my personal record information
including salary information, disciplinary reports, and job performance. I hereby release the Facility, it's agents, and my previous
employers from any liability or damages on account of having furnished such information.

Initial

       

I understand and agree that any claim or lawsuit relating to my services with the Facility must be filled no more than six (6)
months after the date of employment action that is the subject of the claim or lawsuit, including any claims or lawsuits arising out
of state and federal civil rights statutes. I understand that any lawsuit filed outside of this limitations period is barred forever. I
waive any limitations period to the contrary.

Initial

       

I understand and agree that under Michigan law, disabled applicants and employees may request an accommodation for their
disability by notifying the Facility, in writing, of the need for an accommodation within one hundred and eighty two (182) days of
the date the individual knew or reasonably should have known that an accommodation was needed. Failure to do so will preclude
the claim that the Facility failed to accommodate this disability.

Initial

       

If hired, I understand and agree that I am an at-will employee, and that my employment may be terminated by the Facility or me,
at any time, with or without notice, and without or without cause, except as required by law or written contract. I understand this
application does not constitute an agreement or contract for employment for any specified period of time.

Initial

       

I understand and agree that any employment offer will be contingent upon the successful completion of a pre-employment
physical, criminal background checks, drug screen, reference checks, education/licensure/certification verification (if applicable),
credit checks (if applicable) and driving record check (if applicable). I grant the Facility my permission to conduct any such pre-employment
test or verification, including a pre-employment drug screen.

Initial

       

I understand and agree that any employment offer will be contingent upon the successful completion of a pre-employment
physical, criminal background checks, drug screen, reference checks, education/licensure/certification verification (if applicable),
credit checks (if applicable) and driving record check (if applicable). I grant the Facility my permission to conduct any such pre-employment
test or verification, including a pre-employment drug screen.

 

Signature Date


Signature (enter name)



*NOTE: The Provisions of the Fair Credit Reporting Act may be applicable if a credit report on the applicant is obtained and considered.

 







       
 
 
 

Houghton County Medical Care Facility
1100 W. Quincy Street • Hancock, Michigan 49930

(906) 482-5050 tel

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