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Employment Application Form

We support equal employment opportunities and do not discriminate based upon race, color, religion, age, sex, marital status, national origin, disability, genetic information, height or weight or status as a qualified Vietnam era or special disabled veteran, or other classification protected by law. Acceptance of this application does not imply that the applicant will be hired.

Employment Interest

 

 

Full Time Part Time Casual Temporary
 

Days Afternoons Midnights Varied Shifts Weekends

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Identification





 

   
   
 
 

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Affiliates

Please check any affiliates of Blue Water Health Systems where you have been employed:

Port Huron Hospital
Marwood Nursing
      & Rehab
Tri-Hospital EMS

Please list any friends/relatives employed at Port Huron Hospital:

Name
Department
Relationship
Name
Department
Relationship
Name
Department
Relationship

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Personal Background

Are you 18 years of age or older? Yes No
In accordance with OIG guidlines, have you ever been sactioned by MEDICARE or MEDICAID? Yes No

Have you ever been convicted of any crime or held responsible for any civil infraction? Yes No
Are any felony proceedings pending against you? Yes No

Note: A conviction or criminal proceeding will not necessarily be a bar to employment, depending on relevant factors with will be taken into account.

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Education

School Name & Address of School Course of Study Dates Already Graduated? Diploma / Degree
High School      
Yes
GED
No
 
College / University      
Yes
No
 
Other      
Yes
No
 

Professional Licenses / Certification

Type of License / Certification State or Organization Expiration Date

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Military Service

 Were you in the armed forces?  Yes No
If yes, which branch?
Dates of Service From   To  
Describe any specific job-related training received in the military:
 

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Skills

Check any of the following skills or knowledge that you might have:
Typing (WPM )
Word Processing
Data Entry
Dictation Equipment
Medical Terminology
List any other skills, training or qualification which would support your application: 
 

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Employment

List all employment beginning with the most recent:
Employer
Dates Major Duties and Responsibilities
 
Start
End
Street Address
Scheduled Hours
City, State, Zip
Telephone Supervisor
Final Wage Reason for Leaving
 
Positions Held
Employer
Dates Major Duties and Responsibilities
 
Start
End
Street Address
Scheduled Hours
City, State, Zip
Telephone Supervisor
Final Wage Reason for Leaving
 
Positions Held
Employer
Dates Major Duties and Responsibilities
 
Start
End
Street Address
Scheduled Hours
City, State, Zip
Telephone Supervisor
Final Wage Reason for Leaving
 
Positions Held
Account for all periods of unemployment during the last 5 years:
From month, year To month, year
Reason:
From month, year To month, year
Reason:
Why do you wish to work at Port Huron Hospital?   
What are your goals for the future?   
What are your salary requirements, if any? $  

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Release Authorization

Have you ever been discharged or suspended from employment?
Yes No
If yes, please explain:
Is there any employer you do not wish for us to contact? Yes No
If yes, please indicate which one(s) and reason:
 
Have you ever been employed under any other name? Yes No
If yes, please identify names and relative dates:
 

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Notice to handicapped Applicants

Under Michigan law, an employee or applicant who is handicapped and needs accommodation for employment must notify the employer in writing within 182 days after the need is known. if you are handicapped and require accommodation in connection with your application or your job duties if employed, please inform the Vice President of Human Resources in writing.

Applicant Certification and Agreement

I hereby certify that the facts and information given by me in this application are true and complete without qualification and agree to the following:

  • I have not knowingly withheld any information that might, if disclosed, affect my application unfavorably.   I understand that if any statement made by me on this application or during the pre-hire process is false,  misleading, or a material omission, it will prevent me from being hired or, if hired, it will be grounds for my immediate dismissal, regardless of when discovered by the Hospital
  • I also understand that if an offer of employment is made, it is conditioned upon a satisfactory check of my background and records (criminal, credit, etc.).   If the record check is not satisfactory to the Hospital, the offer of employment will be withdrawn or, if I have been subsequently employed, my employment may be terminated.

I understand that Port Huron Hospital may share my application with its Medical Staff and affiliates.

I authorize an investigation of this application (including my past employment, license/certification, educational history, criminal record, and otherwise), agree to cooperate in such an investigation, and release from all liability or responsibility all persons or entities requesting or supplying such information.

I authorize Port Huron Hospital to release information regarding my employment, including discipline, to prospective employers or others who request such information, and waive any requirement that I receive notice of such disclosures. I further release Port Huron Hospital, its employees and representatives, from all liability in connection with such disclosures.

I understand that, if I am employed, my employment can be terminated at any time and for any reason, with or without cause, at the option of either Port Huron Hospital or myself. This understanding of at will employment supersedes and cancels any prior agreement, commitment, or assurance to the contrary.

No exception to this at will employment is authorized or will be recognized as effective regarding my employment unless such exception is expressly stated in an agreement which is signed by me, the Vice President of Human Resources, and the President of Port Huron Hospital.

I agree to abide by the policies, and rules which Port Huron Hospital may establish and revise from time to time. While there may also be procedures for review of employment decisions, including discipline, Port Huron Hospital retains sole discretion to make final decisions on the meaning, intent, and application of its policies and rules.

I understand that Port Huron Hospital wishes to maintain a safe and drug free workplace. All offers of employment are subject to passing drug tests and medical examinations. If employed, I agree to submit to further drug tests and work related examinations as requested by Port Huron Hospital.

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