Application for Employment

Muskegon Surgery Center (MSC) is an Equal Opportunity Employer. It is and shall continue to be our policy that all persons are entitled to equal employment opportunity regardless of race, color, religion, sex, national origin, age, disability, genetic information, marital status, height, weight, sexual preference or orientation, veteran status or any other status protected by local, state and federal law. It is our intention that all qualified applicants are given equal opportunity and that selection decisions are based only on job-related factors.

Answer each question fully and accurately. No action can be taken on this application until you have answered all questions. In reading and answering the following questions, be aware that none of the questions are intended to imply illegal preferences or discrimination based upon non-job-related information.

Job Information

Job Applied For (required)

Date of Application

Type of Employment Seeking (required)

Full-Time

Part-Time

Temporary

On-Call / Resource

Date available to start work (required)

Personal Information

Name (required)

Phone (required)

Address (required)

City (required)

State (required)

Zip (required)

Are you 18 years of age or older?

Yes

(If you are hired, you may be required to submit proof of age.)

If hired, can you furnish proof you are eligible to work in the U.S.?

Yes

Have you ever applied here before?

Yes

If Yes, When?

Were you ever employed here?

Yes

If Yes, When?

Are you now or do you expect to be engaged in any other business or employment?

Yes

If Yes, What?

How many days of work have you missed during the past year? (Exclude absences due to disability or those covered by the Family and Medical Leave Act)

Number of days?

Have you ever been convicted of a crime?

Yes

If yes, provide details. (A yes answer does not automatically disqualify you from employment; nature of offense, date of occurrence, and job applied for are also considered)

Educational Information

High School/GED

Address

Number of Years Completed

Diploma/Degree/Certificate Received

College or University

Address

Number of Years Completed

Diploma/Degree/Certificate Received

Subjects Studied

Vocational or Technical

Address

Number of Years Completed

Diploma/Degree/Certificate Received

Subjects Studied

Skills

What skills or additional training do you have that are related to the job for which you are applying?

What machines or equipment can you operate that are related to the job for which you are applying?

For Driving Jobs ONLY: Do you have a valid driver’s license?

Yes

Have you had your driver’s license suspended or revoked in the past three years?

Yes

If yes, please explain:

List professional, trade, business or civic activities and offices held. (Exclude labor organizations and memberships that reveal race, color, religion, national origin, sex, age, disability or other protected status.)

Work History

List names of employers in consecutive order with present or last employer listed first. Account for all periods of time including military service and any periods of unemployment. If self-employed, give firm name and business references. Note: A job offer may be contingent upon acceptable references from current and former employers.

Name of Employer 1

Address

Phone

Supervisor

From

Pay

Reason For Leaving

Title/Duties

Name of Employer 2

Address

Phone

Supervisor

From

Pay

Reason For Leaving

Title/Duties

Name of Employer 3

Address

Phone

Supervisor

From

Pay

Reason For Leaving

Title/Duties

Name of Employer 4

Address

Phone

Supervisor

From

Pay

Reason For Leaving

Title/Duties

References

Have you worked or attended school under any other names?

Yes

If yes, give names:

Are you presently employed?

Yes

If yes, whom do you suggest we contact? (Name/Phone):

Have you ever been fired from a job or asked to resign?

Yes

If yes, explain:

Give three professional or personal references, not relatives. Provide name, address and phone number:

Applicant Statement

I certify that the facts and information provided in this employment application are true and complete. I understand that any falsification, misrepresentation, or omission in this application (or on any required documents) will be cause for my denial of employment or immediate termination of employment, regardless of when or how discovered.

I authorize the investigation of any or all statements contained in this application. I authorize, whether listed or not, any person, school, current employer, past employers and organizations to provide relevant information and opinions that may be useful in making a hiring decision. I release from all liability any persons, employers, or organizations supplying such information during the investigation. I also release MSC from all liability which may result from making the investigation.

I understand that if I am extended an offer of employment it may be conditioned upon my successfully passing a complete pre-employment physical examination. I consent to the release of any or all medical information as may be deemed necessary to judge my capability to do the work for which I am applying.

I understand that MSC may request an investigative consumer report from a consumer reporting agency. This report may include information as to my character, reputation, personal characteristics and mode of living obtained from interviews with neighbors, friends, former employers, schools and others. I understand I have the right to make a written request within a reasonable time for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the investigation.

I understand I may be required to successfully pass a drug screening examination. I hereby consent to a pre- and/or post-employment drug screen as a condition of employment, if required. In applying for this position, I am giving MSC permission to conduct a criminal background check, credit check, and/or other appropriate background checks including a licensure check and an OIG exclusion query and I understand that my employment is contingent upon the results.

I understand that any employment offer is contingent upon my providing, within three (3) working days of employment, valid proof of identity and eligibility to work in order to comply with the Immigration Reform and Control Act of 1986.

I agree, if I am offered and accept a position, to conform to all existing and future MSC rules and policies and I understand MSC reserves the right to change wages, hours, benefits, and working conditions as deemed necessary to suit business necessity. I also understand that this application or subsequent employment does not create a contract of employment nor guarantee employment for any definite period of time. I understand that, if employed, my employment will be at-will, meaning that either party can end the employment relationship at any time and for any or no reason.

I have read and reviewed the information provided in this application and the above statements. By signing this application I certify that I understand all parts and have answered all questions completely.

This application for employment remains active for a limited time. Ask the human resources representative for details

Enter your name to electronically sign:

Date: