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CAH Job Application

Personal Information
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Other Phone

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Please make a selection.		 Are you legal authorized to work in the United States?
Please make a selection.
 
Employment Desired
Position(s) Applied for
Status Desired:
   
Is there any circumstance which would keep or hinder you from performing any duty of the position or working any assigned shift?
Days Available for Full or Part-time work:  
Available any shift?
Please make a selection.
Shifts Preferred
Have you ever been employed by this organization?
Please make a selection.
List the names of relatives employed in the organization

We offer equal opportunity employment to all individuals and do not discriminate on the basis of race, color, religion, national origin, sex, marital status, age, handicap, disability, height or weight, unless required to do so by law or bona fide occupational qualification. It is the policy of the employer to provide any reasonable accommodations required by law. The questions on this application form are intended to be non-discriminatory in nature, and applicants are not required to submit any information which could be used for discriminatory purposes.

Background Information
Dates of U.S. Military or Naval Service Rank upon discharge
Are you presently in the military (active or reserve)?
Please make a selection.		 If yes, what is your present rank or status?
 
Have you ever been convicted of any crimes of any type which resulted in any penalty, including fines, payment of costs, incarceration, diversion, advisement, or some other resolution?
Please make a selection.
If yes, please explain
   
Are there any felony charges pending against you?
Please make a selection.
If yes, please explain
   
You will not be refused employment solely because of a conviction of a crime. Rather, the organization’s decision will be determined on whether the conviction relates in some way to the position applied for.
Education & Training
School Level School Name Address, City, State No. of Years Completed Type of Diploma, Certificate, or Degree Received

High School
College
College
Graduate School
Nursing/Other School
 
Please list any work training programs, seminars, extra curricular activities, or any other educational experiences relevant to the position(s) applied for
 
Currently taking course(s)
Please make a selection.		 If yes, what is your area of study?
School
Other relevant education and training information    
 
Professional Skills & Licensure
Typing (WPM) List: office skills, computer/software skills, and hospital or industrial equipment skilled to operate:
Shorthand (WPM)
           
PROFESSIONAL LICENSES AND/OR CERTIFICATES      
Type State Issued Date Issued Expiration Date Number
           
FOREIGN AND OTHER LANGUAGE SKILLS, INCLUDING SIGNING: If required by, or helpful to, the position(s) applied for, please complete
Language Speak Read Write  

 

 
Experience
List all previous and current employment, including paid employment, volunteer work, or work in the U.S. Armed Forces
List last or present employment first, attach resume (if you have one), and use separate paper to list additional employers.
 
Start Date
End Date
Employer
Supervisor
 
 
 
Start Date
End Date
Employer
Supervisor
Last rate of pay
Job Title
  Reason for leaving
  Describe in detail the work you performed
 
Start Date
End Date
Employer
Supervisor
Last rate of pay
Job Title
  Reason for leaving
  Describe in detail the work you performed
 
Start Date
End Date
Employer
Supervisor
Last rate of pay
Job Title
  Reason for leaving
  Describe in detail the work you performed
 
Have you ever been discharged from any employment?
Please make a selection.
    If yes, please state the employer, when your employment ended, and why you were discharged
Please explain any gaps between employment:

It is this employer’s policy to check with previous employers as references.
Indicate any of the above employers you do not want us to contact:

References
List three references (not relatives or former employers):    
  Name Address Phone Number Occupation
1
2
3

Certification

PLEASE READ CAREFULLY BEFORE SUBMITTING THIS APPLICATION

I certify that all statements made on this application are true and that I have not knowingly withheld any facts or circumstances which might, if disclosed, affect my application.

I fully understand that the misrepresentation or omission of facts or circumstances will be sufficient cause for rejection of my application if the Organization has not employed me, and for immediate termination if the Organization has employed me.

I authorize the investigation of all statements contained in this application and the further investigation of any information required to determine my qualifications for the position(s) for which I am applying.

I authorize former employers, academic institutions, and other references to release any information required to determine my qualifications for the position(s) for which I am applying and hereby release all individuals and organizations from any liability or damages which may result from furnishing such information. I waive any right, under Public Act 397 of 1978, to receive written notice from this Organization or former employers that such information has been released.

A copy of this Certification serves as sufficient authorization, and may be considered to be in compliance with any law, for the release of whatever information is sought. I hereby agree to sign any documents or authorization which might be necessary to conduct an appropriate investigation of the information contained in this application.

In consideration of my employment, I agree to inform myself of and conform to the policies and procedures of the Organization and I also understand and agree that my employment and compensation is for no definite period and is at will, and may, regardless of time and manner or payment of my wages and salary, be terminated at any time, with or without cause or notice, at the option of either the Organization or myself. I also understand and agree that the Organization has the right to unilaterally modify and/or terminate any policies, practices, procedures, and standards it has adopted or implemented to the extent not limited by law or contract. I acknowledge that no representative of the Organization, other than the Chief Executive Officer and his/her designee, has either the power or authority to enter into any agreement for employment for any specified period of time, or to make any representations or agreements contrary to the foregoing, unless that agreement is in writing and signed by the Chief Executive Officer of the Organization or his/her designee.

I understand that the Organization may require the successful completion of a urinalysis for drug testing purposes, and criminal background check as a condition of employment. By submitting this Application for Employment, I hereby consent to both.

I hereby acknowledge that I have read and understand the preceding statements, and that my affirmation to the above is hereby voluntarily given.

In clicking the submit button below you are signing and agreeing to the above statement:

**Note - Your application has successfully submitted when you are returned to the homepage. Otherwise scroll up for possible errors.

14700 Lake Shore Drive
Charlevoix, MI 49720
231-547-4024
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