Home / Job Application Job Application Please enable JavaScript in your browser to complete this form.General Information - Step 1 of 6POSITION APPLIED FOR *Have you ever filed an application with us before? *YesNoWhen? *Were you referred to us by an employee? *YesNo PLEASE LIST THE NAME OF EMPLOYEE *Referral Source *Name *FirstMiddleLastAddress: (Street) *CIty *State *Zip Code *Telephone No. *Email Address *Specify any days or times you are not available for work: *What shift(s) are you willing to work? *Salary Expectation *Per *What shift(s) are you willing to work? *Employment Status Desired *Full TimePart TimeHave you ever been employed by the Oceana County Medical Care Facility? *YesNoDate Started *Date Left *In What Department *In What Position *Reason for leavingAre you a U.S. Citizen? *YesNoDo you have a legal right to remain permanently in the United States? *YesNoIf employed, can you submit verification of your legal right to remain in the U.S.? *YesNoWhat prompted your application? *Do you have a telephone at your residence? *YesNoDo you have a reliable form of transportation available to you to go to and from work? *YesNoMILITARY SERVICE ServiceBranchDate of ServiceFromToWere you honorably discharged?YesNoReserve StatusNextEMPLOYMENT HISTORY- List your last four employers, or all employers for the last ten years, whichever is greater. Attach additional signed sheets if necessary. Also list and explain any period(s) of unemployment. Please answer all inquiries. “See Resume” is not acceptable.Employer’s Name *Dates Worked (month and year)From *To *Address (Street, City, State and Zip Code) *Telephone *Supervisor (Name & Title) *Your Title *Your Salary *Duties & Responsibilities *Reason for leaving *2Add employer (2)Employer’s Name *Dates Worked (month and year)From *To *Address (Street, City, State and Zip Code) *Telephone *Supervisor (Name & Title) *Your Title *Your Salary *Duties & Responsibilities *Reason for leaving *3Add Employer (3)Employer’s Name *Dates Worked (month and year)From *To *Address (Street, City, State and Zip Code) *Telephone *Supervisor (Name & Title) *Your Title *Your Salary *Duties & Responsibilities *Reason for leaving *4Add Employer (4)Employer’s Name *Dates Worked (month and year)From *To *Address (Street, City, State and Zip Code) *Telephone *Supervisor (Name & Title) *Your Title *Your Salary *Duties & Responsibilities *Reason for leaving *Are you currently on “layoff” status and subject to recall? *YesNoHave you ever been discharged by an employer or resigned in lieu of discharge? *YesNoHave you ever been disciplined (other than discharged by an employer? *YesNoIf you answered yes to either of the two previous questions, explain all such incidents, giving facts, dates, describing any action you took and any resolution, on an attached signed sheet. How much time have you missed from work in the past twelve months? *Do you have a valid driver’s license? *YesNoPreviousNextEDUCATION High School *Location *Degrees *Business School *Location *Degrees *College/University *Location *Degrees *Trade/Vocational School *Location *Degrees *Extracurricular activities & honors received in school *PreviousNextPROFESSIONAL LICENSES, REGISTRATIONS, AND/OR CERTIFICATIONS List all states in which you are or have been licensed or certified and any national certifications. *Attach additional pages if necessary. * Click or drag files to this area to upload. You can upload up to 10 files. Have you ever had any professional license or certification placed under investigation, disciplined, suspended, revoked or put on probation? *YesNoHave you ever been denied a license or certification? *YesNoYou answered yes to either above questions, explain in detail on an attached signed statement. *PreviousNextMISCELLANEOUS Do you have any felony charges pending against you? *YesNoHave you ever been convicted or pled guilty or nolo contendere to a crime? *YesNoYou answered yes to either of the two proceeding questions, explain by giving the date, nature of the offense and circumstances in an attached, signed statement. Conviction of a crime will not necessarily disqualify an applicant from employment. *Are you 18 years of age or older? *YesNoAre you able to perform the duties of the job for which you have applied? *YesNoReferences: Give the name, address and telephone numbers of three references who are not related to you. Reference 1 NAMEADDRESSTELEPHONE NO.EMAILReference 2 NAMEADDRESSTELEPHONE NO.EMAILReference 3 NAMEADDRESSTELEPHONE NO.EMAILPreviousNext CERTIFICATION I understand that I may be required to submit to a physical examination, which may include a drug test, prior to beginning employment and that I must satisfactorily pass such an examination to obtain employment. I have read and fully understand the questions on this application for employment. I have completely, truthfully, and accurately answered each and every question to the best of my knowledge. I understand that all the inquiries on this application are subject to verification and authorize any schools that I have attended, licensing and certification boards, law enforcement agencies and current and previous employers to release any requested information to the Facility. I also specifically waive written notice from any and all former employers regarding their disclosure to the Facility of any prior disciplinary action and waive any claim against the Facility and current or former employers arising from such investigation of disclosure. I understand that any misrepresentation of the information I have supplied or failed to supply can result in a rejection of this application or, if I have been hired, an immediate dismissal at the sole discretion of the Facility. I understand and agree that in the absence of an express written contract or agreement to the contrary, signed by an authorized representative of the Facility and by me or my authorized representative, any employment I accept shall be for an indefinite term and may be terminated at any time with or without cause either by me or at the will and sole discretion of the Facility regardless of any contrary provisions in any other forms, manuals, handbooks or other documents. Similarly, such employment shall be at the wages, benefits, hours and conditions as the Facility may determine and change from time to time and I agree to abide by any rules, regulations, policies and procedures that may be established from time to time. I understand that no one, other than an authorized representative of the Facility has any authority to enter into an agreement with me contrary to the provisions of this paragraph and that any such agreement must be in writing and signed by such authorized representative or it shall not be effective. It is with full understanding and agreement with the provisions of this Certification that I will accept any employment offered to me.Signature of Applicant *Clear SignatureDate *PreviousSubmit