EMPLOYMENT APPLICATION
AN EQUAL OPPORTUNITY EMPLOYER

Federal and State laws prohibit discrimination on the basis of age, sex, race, color,
religious creed, national origin, marital status, ancestor or disability.
Date: 7/29/2010
LAST NAME
FIRST NAME
 M.I.
 MAIDEN NAME
PRESENT ADDRESS
 CITY
 STATE
 ZIP CODE
PHONE NUMBER
 SOCIAL SECURITY NUMBER

Position Applied for:  Date Available:
Check type of employment desired:
Shift Preference:
Are you willing to work overtime? 
Are you:
legally entitled to work in the United States?
After employment you will be required to show proof of citizenship, VISA, or alien registration number.
a previous applicant?
a previous employee of Saginaw Community Hospital or HealthSource Saginaw?
If so, state date, department and position held:
Place a check to indicate source of referral:



Please enter name of advertisement publication, name of employee, Internet advertisement, or other:
Other than minor traffic violations, have you ever been convicted of a crime?
If yes, identify crime and date of conviction:

(A positive response to this question will not necessarily bar you from being considered for employment.)

In case of emergency notify:
Name:  Phone: 
Name:  Phone: 

EDUCATION AND TRAINING
TYPE OF SCHOOL
 NAME AND LOCATION
OF SCHOOL		 TYPE OF DEGREE EARNED
 MAJOR & MINOR
FIELDS OF STUDY
High School Diploma? 
College or University
Business or Tech. School
Other Training (Explain)

PROFESSIONAL INFORMATION
(if applicable)

Professional Certificate or licenses held: Expiration Date
State any additional information you feel may be helpful to us in considering your application (such as any specialized training; skills; apprenticeships; honors received; professional, trade, business or civic organizations or activities; foreign language abilities; computer skills; machinery operated, etc.

MILITARY SERVICE
Branch: 
From:    To:    Current Status: 
Special U.S. Military Training, Education, or Work Experience:


EMPLOYMENT HISTORY
Start with the most recent position.

Present or Last Employer
 Address


Phone Number:
Start Date
Type of Business
 End Date
Job Title
 Reason for Leaving
 Starting Salary
 Final Salary
Description of job and duties:
Supervisor's Name and Title
 If still employed, may we check references?


Present or Last Employer
 Address


Phone Number:
Start Date
Type of Business
 End Date
Job Title
 Reason for Leaving
 Starting Salary
 Final Salary
Description of job and duties:
Supervisor's Name and Title
 May we check references?


Present or Last Employer
 Address


Phone Number:
Start Date
Type of Business
 End Date
Job Title
 Reason for Leaving
 Starting Salary
 Final Salary
Description of job and duties:
Supervisor's Name and Title
 May we check references?

REFERENCES
List three references not related to you and by whom you have not been employed.

Name Occupation Phone Number Address Years Known

ADDITIONAL INFORMATION ABOUT YOURSELF WHICH WILL
AID IN EVALUTATING YOUR CAREER INTEREST AND ABILITIES:

CERTIFICATION:
I understand that I am required under Sections 210.18 of the Michigan Handicapper Civil Rights Act to notify an employer that I need an accommodation within 182 days after the date that I know or reasonably should have known that an accommodation is needed.  I understand that any false or misleading statements on this application or failure to disclose material or information will cause immediate rejection of this application or my immediate dismissal if hired.  I authorize previous employers and the references listed above to give you any and all information concerning my previous employment and any pertinent information they may have, personal or otherwise, and release all parties from liability for any damage that may result from furnishing this information to you.  If I am offered employment with HealthSource Saginaw, I understand that such offer is based on successful completion of a pre-placement medical evaluation and a drug/alcohol screen.  This conditional offer of employment may be withdrawn if I fail to demonstrate the ability to perform the essential functions of the job, have a positive drug/alcohol screen or if I refuse to complete the pre-placement medical evaluation or drug/alcohol screen.

I authorize the applicable county Sheriff Department or Michigan State Police to release records of all criminal conviction and or history of felony arrests to the Facility.

If I am hired by HealthSource Saginaw, I understand and agree that my employment is for no fixed term, and I or my employer may terminate the relationship at any time for any reason.



TO OUR APPLICANTS:  Thank you for considering HealthSource Saginaw as a prospective employer.  Normally your application will be kept in our active files for six months.  If you have not been contacted for an interview within six months, you are welcome to reapply.

ATTACH  YOUR RESUME:

 

Non-Discrimination/Equal Employment Opportunity Statement

HealthSource Saginaw is committed to non-discrimination, equal employment opportunity and affirmative action. Accordingly, discrimination against any individual for reasons of race, color, creed, religion, sexual orientation, national origin, sex, age, disability or veteran status is specifically prohibited.

APPLICANT INSTRUCTIONS

  • This form will be submitted with your on-line application. You need only submit this form one time, even if you are applying for more than one position.
  • Providing this information is voluntary.  Data collected will be handled confidentially to the extent allowed by law.  Disclosure of the information will not result in any adverse employment action.
VOLUNTARY INFORMATION

This information is being requested in accordance with federal regulations. The information is voluntary and will not be used when considering you for employment with our company.

Racial or Ethnic Group

: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.

: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

: A person having origins in any of the black racial groups of Africa.

: A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian Subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

:  A person having origins in any of the original peoples of North and South America(including Central America), and who maintain tribal affiliation or community attachment.

:   All persons who identify with more than one of the above five races.

Gender

Military Service

What prompted you to apply to HealthSource Saginaw?

Other: