ALLEGAN COUNTY MEDICAL CARE COMMUNITY EMPLOYMENT APPLICATION

• Applicants who need reasonable accommodation to ensure equal opportunity in the application process should immediately inform the person who provided this application form. • Persons hired by Allegan County Medical Care Community are required to present proof of identification and of their legal eligibility to work in the United States prior to beginning work. • ALLEGAN COUNTY MEDICAL CARE COMMUNITY - An Equal Opportunity Employer - APPLICATION FOR EMPLOYMENT

Allegan County Medical Care Community does not return resumes, transcripts, letters of reference and other information submitted with the application process.

In compliance with federal and State equal employment opportunity laws qualified applicants are considered for all positions without regard to race, color, creed, religion, sex, national origin, age, marital or veteran status, sexual orientation, or the presence of a non-job related medical condition or disability. The Americans with Disabilities Act requires employers to provide reasonable accommodations for known physical or mental disabilities of applicants.

EDUCATION

Please list education or specialized experience that relates to the position(s) for which you are applying. Exclude names or terms that indicate, for example, race, color, religion, sex, disability, or national origin.

EMPLOYMENT EXPERIENCE

List beginning with your current or last position. Include military service assignments and volunteer activities. Exclude names or terms that indicate , for example, race, color, religion, sex, disability, or national origin.

PREVIOUS EMPLOYER #1

PREVIOUS EMPLOYER #1

PREVIOUS EMPLOYER #3

PERSONAL REFERENCES

Please provide a series of personal references as follows: References Name / Relationship to Yourself / How long you have known him/her

PROFESSIONAL REFERENCES

Please provide a series of personal references as follows: References Name / Relationship to Yourself / How long you haveknown him/her

REQUIRED DEMOGRAPHIC INFORMATION

As a prospective Allegan County Medical Care Community employee, I understand that the Community is prohibited by the Federal Nursing Home Reform Act of 1987, Public Act 28 of 2006, Public Act 303 of 2002, and Public Act 368, (Section (333.20173) of the Michigan Public Health Act of 1978, from employing any individual who has been found guilty by a court of law of abusing, neglecting or mistreating a nursing home resident or who has had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, mistreatment of nursing home residents or misappropriation of their property. This form must be submitted with this application for employment and when required during the term of employment As a prospective Allegan County Medical Care Community employee, I understand that the Community is prohibited by the Federal Nursing Home Reform Act of 1987, Public Act 28 of 2006, Public Act 303 of 2002, and Public Act 368, (Section Please provide your living addresses, starting with your current address and working back for the past 15 years. You must continue on the reverse side of this form if you need extra space

ADDITIONAL DEMOGRAPHIC INFORMATION

I have truthfully and accurately completed the information requested by Allegan County Medical Care Community in order to enable the Community to complete required Federal and State of Michigan Criminal History Background, State, Nurse Aide Registry and other licensing board checks. I consent to any and all checks required by Allegan County Medical Care Community pursuant to the requirements of State and Federal Law. I further understand that these required checks will include checks with the Nurse Aide Registry, the State Police, State licensing boards and an FBI fingerprint check. In making this application for employment, I understand an investigation will be completed so that information may be obtained through interviews of my references, criminal background and physical examination including urinalysis for drug testing purposes and or alcohol testing as a condition of my employment. I have the right to make a written request within a reasonable time period to receive information regarding results of this investigation. I authorize Allegan County Medical Care Community to communicate with persons listed as references and former employers. I agree to hold such persons harmless with respect to any information they may provide about me. • If employed, I agree to engage in no outside activity that would involve a material conflict of interest with, or could reflect adversely on the Allegan County Medical Care Community. I understand this decision rests with the community. If employed, I agree to hold in strictest confidence any information concerning the Allegan County Medical Care Community, fellow employees, residents and related family that may come to my attention. In consideration of my employment, if employed, I agree to comply with the employment policies and regulations governing the Allegan County Medical Care Community. I understand that my employment and compensation can be terminated, with or without notice, at any time, at the option of either the community or myself. I understand that completion of this application for employment does not guarantee that I have been employed by the Allegan County Medical Care Community. I hereby affirm that my answers to these statements and questions are true and correct to the best of my knowledge. I have not knowingly withheld any fact or circumstance that would, if disclosed, affect my application unfavorably. I understand that any misrepresentation, deception, or false statement made in this employment application process may result in my not being considered for employment, and if not discovered by the community until after my becoming employed, is grounds for, and may result in my immediate termination. I understand the Allegan County Medical Care Community requires the successful completion of a urinalysis for drug testing purposes and/ or an alcohol test, and criminal background check as a condition of employment. I hereby consent to any of these tests as deemed necessary by the community. I hereby authorize my former employers to provide any information regarding my employment. I authorize any police agency to provide any information regarding any record they may have on me. I authorize any educational institution listed on this application to release information regarding any record they may have on me. I certify that the statements made by me in this application are true, complete, and correct, and made in good faith.
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