Employment Application False, Misleading or Incomplete Information will Prevent Applicants from Being Hired



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Employment Application
False, Misleading or Incomplete Information will Prevent Applicants from Being Hired 

Applicant Data

First Name
     

Middle Name
     

Last Name
     

Other name used (if different from your present name)
      

Address
     




Apt #     
 

City
     

State/Province
     

Zip/Postal Code
     




Primary Phone #
     

Mobile Phone #
      

Work Phone #
      

E-mail Address
     

Have you ever worked for Henry Ford Health System or an affiliate, directly or through an agency or as a contractor?
☐Yes    ☐No

If yes, please provide location:
      


Last Month/Year Worked
      

Do you have an outstanding loan obligation to Henry Ford Health System or an affiliate?
☐Yes    ☐No

If yes, please provide details
      

Are you at least 18 years of age?
☐Yes    ☐No

Are you legally authorized to work in the USA?
☐Yes    ☐No

Will you require future sponsorship for employment visa status?
☐Yes    ☐No

Are you able, with or without reasonable accommodation, to perform the essential functions of the job for which you are applying?
☐Yes    ☐No

Are you or have you ever been excluded from participation in a Governmental Heath Care Payment Program?
☐Yes    ☐No

If yes, please provide details

     
 






 

Work Experience

Have you ever been fired or asked to resign by an employer?
☐Yes    ☐No

If yes, please provide details
      

Do you have any time commitments to any other employer which may affect your employment with Henry Ford Health System?
☐Yes    ☐No

If yes, please provide details
      

Do you have any gaps in your employment history that is greater than 30 days?. Be sure to account for all periods of time including military service and any period of unemployment.
☐Yes    ☐No 

If yes, please provide details:       


List all employers, beginning with your present or most recent and include temporary experience and job related volunteer experience.

Please complete employment section for your current and/or most recent employer and your last three employers! The fields highlighted in yellow for the first employer are required. For each additional employer; the same fields are also required, but not highlighted in yellow. (See resume is not acceptable)







1. Company Name
     

Address
     

City
     

State/Province
     

Zip/Postal Code
     

From:
     

To:
     

Are you currently employed with this Employer?
☐Yes    ☐ No 

Your Title     


Pay Rate     



Your Department

     


Supervisor’s Name
     

Supervisor's Title
     

Supervisor's Phone Number
     

Reason for Leaving:
     

Have you ever been disciplined by this employer?
☐Yes    ☐ No

If yes, please provide details:
      

Describe your major duties:
     






2. Company Name
     

Address
      

City
     

State/Province
     

Zip/Postal Code
     

From:
     

To:
     

Your Title
     

Pay Rate
     

Your Department

  


Supervisor’s Name
     

Supervisor's Title

     


Supervisor's Phone Number
     

Reason for Leaving:

     


Have you ever been disciplined by this employer?
☐Yes    ☐ No

If yes, please provide details:   
   

Describe your major duties:
     

     








 

Criminal History

1. Have you ever been charged with, indicted for, convicted of, or pled guilty or no contest to any felony, regardless of the sentence you received, whether you were given probation, received a deferred adjudication or a pardon, or the conviction was sealed?

☐Yes  ☐No



If yes, please provide details, including dates, location, results, fine paid or time served, etc.
     

 


2. Have you ever been convicted of, or pled guilty or no contest to any misdemeanor, or other criminal offence or violation (excluding minor traffic violations, but including any substance related offense e.g., driving while intoxicated or under the influence) regardless of the sentence you received, whether you were given probation, received a deferred adjudication or a pardon, or the conviction was sealed?
☐Yes    ☐ No

If yes, please provide details, including dates, location, results, fine paid or time served, etc.
     

 


3.  Are there any pending charges or investigations filed against you in a court of law, regulatory agency and/or licensing agency that are related to performing the duties of the position for which you have applied?
☐Yes   ☐No

If yes, please provide details
     

 





I hereby certify that the information provided by me on this form as well as all statements made and information submitted by me in connection with my application for employment are true and accurate.  I authorize Henry Ford Health System or its designated agents to investigate all such information for accuracy. I release from all liability anyone providing information in response to such investigation. I understand and agree that if any of the information or statements is false, misleading or incomplete, it will prevent me from being hired, or if hired, it will be grounds for my termination from employment.  I declare that I am not using any illegal drug and do not engage in improper self-medication.  I understand that in accordance with HFHS policies and procedures, following a conditional offer of employment, I will be subjected to a pre-employment health screen.  The health screen will include drug testing and I understand that a positive result on the drug test may disqualify me from employment.

I understand that while the initial hours, shifts, facility and days of work were explained during the interview process, they are not guaranteed during my employment and that I may be required to work other shifts, hours, days, or at other facilities as organizational needs require. I understand that employment is not guaranteed and that I can be terminated at will without cause and without notice.  I understand that this application does not constitute a contractual agreement; and that policies and procedures may be changed with or without notice.



Henry Ford Health System is an equal opportunity employer and does not discriminate on the basis of race, color, gender, religion, national origin, age, height, weight, marital status, military or veteran status, disability, or any other illegal criteria. Henry Ford Health System is committed to making reasonable accommodations for qualified disabled applicants and employees if the accommodation will allow the individual to perform the essential functions of the job. A qualified disabled applicant or employee who feels he/she needs an accommodation to enable him/her to perform the essential functions of a job at Henry Ford Health System should notify the Human Resource department in writing within 182 days of the date he/she knows or should have known that an accommodation is needed. Failure to provide such notice precludes a claim that Henry Ford Health System failed to make an accommodation under the Michigan Persons with Disability Act.

PLEASE READ THE ABOVE STATEMENTS AND SIGN APPLICATION

Signature

(checking the box above is equivalent to a handwritten signature)





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