Employment Application

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Canal View - Houghton County is an equal opportunity employer and does not discriminate in employment due to race, color, religion, sex, age, national origin, handicap, marital status, financial 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 submit this application.

Personal Information

First Name(Required)

Middle Initial(Required)

Last Name(Required)

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

Street(Required)

City(Required)

State(Required)

Zip(Required)

How many years have you lived at this address?(Required)

Phone(Required)

Previous Address(Required)

How many years did you live there?(Required)

Job you are applying for:(Required)

Rate of pay expected(Required)

How did you learn of this opening?(Required)

Indeed, Web Page, Referred by, etc.

Status preference(Required)

Full-time

Part-time

Shift preference(Required)

Have you worked for us before?(Required)

Yes

When?

Please list any relatives working for us:

If hired, when can you start?(Required)

Month

Day

Year

Have you applied for a career with Canal View within the last six months?

Yes

Professional Licenses and/or Certifications

Type

Organization or State Issue

Number

Date

Month

Day

Year

Type

Organization or State Issue

Number

Date

Month

Day

Year

Type

Organization or State Issue

Number

Date

Month

Day

Year

If hired, do you have a reliable means of transportation to get to work?(Required)

Yes

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

Yes

Please describe and/or explain your work limitations.

Are you subject to a layoff or recall?(Required)

Yes

Are you 18 years old or over?(Required)

Yes

Can you provide a work permit?(Required)

Yes

Are you legally eligible for employment in the united states?(Required)

Yes

Canal View - Houghton County 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 Canal View - Houghton County, 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?

Have you ever served in the armed forces?

Yes

Date served from

Month

Day

Year

Date served to

Month

Day

Year

Rank at discharge

Type of discharge

Reserve Status

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

Personal References

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

Reference #1

Name and occupation(Required)

Address(Required)

Phone(Required)

Reference #2

Name and occupation(Required)

Address(Required)

Phone(Required)

Reference #3

Name and occupation(Required)

Address(Required)

Phone(Required)

Prior Work History

Job #1

Employer Name, address and phone

Date worked from

Month

Day

Year

Date worked to

Month

Day

Year

Starting pay

Ending pay

Supervisor Name and Title

Reason for leaving

Please describe the work you did.

Job #2

Employer Name, address and phone

Date worked from

Month

Day

Year

Date worked to

Month

Day

Year

Starting pay

Ending pay

Supervisor Name and Title

Reason for leaving

Please describe the work you did.

Job #3

Employer Name, address and phone

Date worked from

Month

Day

Year

Date worked to

Month

Day

Year

Starting pay

Ending pay

Supervisor Name and Title

Reason for leaving

Please describe the work you did.

Job #4

Employer Name, address and phone

Date worked from

Month

Day

Year

Date worked to

Month

Day

Year

Starting pay

Ending pay

Supervisor Name and Title

Reason for leaving

Please describe the work you did.

May we contact the employers listed above?

Yes

Please indicate which employers you do not wish us to contact.

Occasionally, the form of an application makes it difficult for an individual to adequately summarize his or 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

Information Accuracy(Required)

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 cancellation of my consideration for employment or may be the cause for dismissal if I have been employed.

I understand and agree.

Release of Information(Required)

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 or account of having furnished such information.

I understand and agree.

Limitations Waiver(Required)

I understand and agree that any claim or lawsuit relating to my services with the Facility must be filed 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.

I understand and agree.

Disability Accommodation(Required)

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 the 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 a claim that the Facility failed to accommodate this disability.

I understand and agree.

At-Will Waiver(Required)

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 with 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.

I understand and agree.

Pre-Employment Check Waiver(Required)

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.

I understand and agree.

Consent(Required)

I have read, understand, and agree to the above statements and conditions of employment. I have read, understand, and agree to allow the Facility to confirm the information contained in this application and accompanying documents.

I understand and agree.

Date

Month

Day

Year

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

CAPTCHA

This field is for validation purposes and should be left unchanged.