Eaton Rapids Medical Center : Employment : Apply

Please enter the following:

First Name:

Last Name:

Middle Name:

Address:

City:

State:

Zip:

Home Phone:

Business Phone: Ext:

Have you ever been employed at Eaton Rapids Medical Center:

Yes

No

Pay expected:

When will you be available to begin work?

Are you over 18 years of age?:

Yes

No

Have you ever been bonded?:

Yes

No

Are you legally eligible for employment in the United States?:

Yes

No

Have you ever been convicted of a crime?
(A "Yes" answer will not automatically disqualify you.)

Yes

No

State name of relatives and friends working for us, other than your spouse.

Other special training or skills
(languages, machine operation, etc.)

characters left.

Membership in Professional or Civic Organizations
(Exclude those which may disclose your race, color, religion or national origin)

characters left.

High School Information

Last Grade Completed:

Name of High School:

GED:

State:

Additional Education Experience(s):

School Name:

School Location:

School Course of Major Studied:

Degree:

Employer #1

Company Name:

Do Not Contact Employer

Address:

City:

State:

Zip:

Phone:

Name of Supervisor:

State Job Title and describe your work:

characters left.

Employment Start Date:

Employment End Date:

Still Employed

Weekly Pay Start: Last:

Reason for Leaving:

characters left.

Employer #2

Company Name:

Do Not Contact Employer

Address:

City:

State:

Zip:

Phone:

Name of Supervisor:

State Job Title and describe your work:

characters left.

Employment Start Date:

Employment End Date:

Still Employed

Weekly Pay Start: Last:

Reason for Leaving:

characters left.

Employer #3

Company Name:

Do Not Contact Employer

Address:

City:

State:

Zip:

Phone:

Name of Supervisor:

State Job Title and describe your work:

characters left.

Employment Start Date:

Employment End Date:

Still Employed

Weekly Pay Start: Last:

Reason for Leaving:

characters left.

Employer #4

Company Name:

Do Not Contact Employer

Address:

City:

State:

Zip:

Phone:

Name of Supervisor:

State Job Title and describe your work:

characters left.

Employment Start Date:

Employment End Date:

Still Employed

Weekly Pay Start: Last:

Reason for Leaving:

characters left.

Military

Did you serve in the US Armed Forces?

Yes

No

Contacts

Name

Phone

Relationship

Years Known

Name

Phone

Relationship

Years Known

Name

Phone

Relationship

Years Known

Upload Resume (optional):

Allowed Resume File Types: .pdf .doc .docx

In filing this application for employment, I authorize Eaton Rapids Medical Center to investigate previous work/personal references in addition to any and all answers given by me on this application regarding background information, previous employment history and educational qualifications. It is further understood that employment for the specific position applied for is contingent upon my being able to medically perform, with reasonable accommodation, the duties of the position.

In consideration of my employment I agree to conform to the policies and procedures of Eaton Rapids Medical Center. I understand the company reserves the right to modify or rescind its policies and procedures without notice and at its discretion.

I also agree that employment with the company is not for any specific period of time, and that I or the company may terminate my employment with or without notice or cause at any time. I understand that no representative of the company, except a corporate officer, has authority to enter into any agreement contrary to the above and that any such agreement by an officer shall be in writing and signed by the officer.

The information provided in this Application for Employment is true, correct and complete. Any misstatement or omission of fact on the application may result in termination of employment.

Eaton Rapids Medical Center

Employment Form

Step #1

Please enter the following:

Step #2

High School Information

Additional Education Experience(s):

Step #3

Employer #1

Employer #2

Employer #3

Employer #4

Military

Step #4

Contacts

Step #5

Press submit to complete the application.