HILLSDALE COUNTY MEDICAL CARE FACILITY & REHABILITATION CENTER
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Employment Application
TELL US ABOUT YOURSELF
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Indicates required field
Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Email
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Home Phone
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Other Phone
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Upload Resume
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Max file size: 20MB
MS Word or compatible .doc file
In case of emergency notify:
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Relationship
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Phone Number
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Position Desired
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Care Associate (CNA)
Neighborhood Nurse (LPN/RN)
Environmental Services
Activities
Nutrition Services
Please select from available positions
Training for this position
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Other specialized training
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(Formal education shown later in this form)
Where now employed?
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Reason desiring change
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Why do you choose nursing home work?
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What prompted you to apply here for employment?
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Hobbies
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Are you related to anyone in our employ?
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YES
NO
IF YES, whom?
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LICENSURE
Professional License #
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Type
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CNA Certificate
Nursing License
Issuing State
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington D.C.
West Virginia
Wisconsin
Wyoming
Expiration Date
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EDUCATION
Level Of Education
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Some High School
Completed High School
Some College
Associate's Degree
Bachelor's Degree
Master's Degree
PhD
Name and location of last School or College
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Date of Completion
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EMPLOYMENT HISTORY
Employer Name
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Employer phone
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Reason for leaving
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Nature of Experience
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From
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To
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May we contact?
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YES
NO
Employer Name
*
Employer phone
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Reason for leaving
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Nature of Experience
*
From
*
To
*
May we contact?
*
YES
NO
Employer Name
*
Employer phone
*
Reason for leaving
*
Nature of Experience
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From
*
To
*
May we contact?
*
YES
NO
BACKGROUND INFORMATION
Have you ever abused, neglected, mistreted or misappropriated the property of a resident of a health care facility?
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YES
NO
What was the nature of the incident?
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Have you ever been convicted of a crime?
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YES
NO
If yes, when?
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What was the nature of the offense?
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SIGNATURE AND SUBMISSION
In signing below, I hereby authorize any information concerning my EDUCATIONAL RECORD, EMPLOYMENT RECORD, or CRIMINAL RECORD, to be released to the Hillsdale County Medical Care Facility of Hillsdale, Michigan. This information is to be used for possible employment with HCMCF, and will not be available for public inspection.
I hereby release such person, agency, partnership or corporation from liability which may be incurred in releasing this information to the Hillsdale County Medical Care Facility, including liability under federal law.
To sign, please type your full name
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Today's Date
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CLICK HERE TO SUBMIT YOUR APPLICATION
Home
COVID-19 Update
About Us
Our Mission
Social Programs
Physicians
Our Staff
Happenings
News
Calendar
Contact
Admissions
General
|
Career Opportunities
Current Openings
Apply Here