LAST NAME	FIRST NAME	M.I.	MAIDEN NAME
PRESENT ADDRESS	CITY	STATE AK AL AR AZ CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA MA MD ME MI MN MO MS MT NC ND NE NV NH NJ NM NY OH OK OR PA RI SC SD TN TX UT VT VA VI WA WI WV WY AB BC MB NB NL NT NS NU ON PE QC SK YT	ZIP CODE
PHONE NUMBER	SOCIAL SECURITY NUMBER

Position Applied for:  Date Available:

Check type of employment desired: Full-TimePart-TimeOn-CallTemporary

Shift Preference: 1st Shift2nd Shift3rd Shift

Are you willing to work overtime?  YesNo

Are you: YesNo legally entitled to work in the United States? After employment you will be required to show proof of citizenship, VISA, or alien registration number. YesNo a previous applicant? YesNo 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: Advertisement Employee Internet Ad Other Please enter name of advertisement publication, name of employee, Internet advertisement, or other: YesNo 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?  YesNo 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? YesNo

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? YesNo

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? YesNo

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.

I have read and agree to these terms

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: