NORTHPOINTE HEALTHCARE SYSTEMS
APPLICATION FOR EMPLOYMENT

Northpointe Healthcare Systems is an equal opportunity employer and shall consider all qualified applicants for all positions without regard to race, color, sex, religion, national origin, age, height, weight, marital status, veteran status, handicap, or any other protected category.

YOU MUST ANSWER ALL QUESTIONS COMPLETELY. FAILURE TO DO SO WILL RESULT IN REJECTION OF YOUR APPLICATION AND YOU WILL NOT BE CONSIDERED FOR EMPLOYMENT.

Position(s) Applied for:
Date:

Last Name
First Name
Middle Name

Address: Street
City
State
Zip

Phone
Email

If you are applying for a position for which driving is a job requirement. Do you presently have a valid driver’s license from the State in which you reside?
Yes No

Driver's License Number:

Are you a relative by birth or marriage to any Northpointe Board member or full-time management employee?
Yes No


If Yes:

Name
Relationship


Are you under 18 years of age?
Yes No
Are you currently working?
Yes No
Are you on lay-off?
Yes No
If yes, are you subject to recall?
Yes No N/A
Will you submit to a drug test?
Yes No
Have you ever been employed by Northpointe?
Yes No
If yes:

Position
Department
Dates

Are you prevented from lawfully becoming employed in this country because of a Visa or immigration status?
(Proof of citizenship or immigration status may be requested upon employment)
Yes No


Have you ever been fired?
Yes No
If Yes, give date, where you worked and explaination:


Are you capable of performing with or without reasonable accommodation (special assistance, equipment or other help), the activities involved in the job or occupation for which you have applied?
Yes No

EDUCATION

High School Vocational /
Technical
College Graduate
School Name, City / State
Did you Graduate? Yes No N/A
Yes No N/A
Yes No N/A
Yes No N/A
Degree / Certificate N/A
Major / Minor N/A

Describe any specialized training, apprenticeships, internships, skills, licenses, certificates, and extra-curricular activities that pertain to the position(s) for which you are applying.


List professional, trade, business group memberships and offices held and volunteer work excluding groups the name and character of which indicate race, color, sex, religion, national origin, age, height, weight, marital status, veteran status, handicap, or any other protected class:


Work/Professional References

(List Individuals who can attest to your work performance. List complete address including street and/or PO Box #, City, State and Zip Code)



Name:
Address:
City,State, Zip:
Title:
Work Phone:
Home Phone:
Cell Phone:
Name:
Address:
City,State, Zip:
Title:
Work Phone:
Home Phone:
Cell Phone:

Name:
Address:
City,State, Zip:
Title:
Work Phone:
Home Phone:
Cell Phone:


Criminal Background Information

NOTE: Any applicant given a conditional job offer will need to be fingerprinted, with eligibility for employment determined by the State of Michigan. Additionally, they will need to be drug-tested prior to final job offer.
Have you ever been convicted of a felony?
Yes No
If Yes, give date, where you worked, and explanation
A conviction record will not necessarily be a bar to employment. Factors such as age, date of offense, seriousness, and nature of violation will be considered.

Have you ever been convicted of an offense or had any substantiated finding of patient or resident neglect, abuse or misappropriation of property?
Yes No

If Yes, completely describe including location, date and conditions:

Employment History

List each job held. Start with your present or last job first.

Employer: Dates Work Performed
From To
Address & Telephone:
Job Title: Hourly Rates
From To
Supervisor:
Reason(s) for Leaving:
Employer: Dates Work Performed
From To
Address & Telephone:
Job Title: Hourly Rates
From To
Supervisor:
Reason(s) for Leaving:
Employer: Dates Work Performed
From To
Address & Telephone:
Job Title: Hourly Rates
From To
Supervisor:
Reason(s) for Leaving:

WAIVERS AND ACKNOWLEDGMENTS

Please read carefully before signing

  1. I certify that the information in this application is true, complete and correct to the best of my knowledge and understand that falsification, misleading, misrepresentation or omission of any information submitted in connection with my application or interview, whether in this documents or not, may result in the rejection of application or, if hired, dismissal.
  2. I authorize the references and current and former employers listed in this application to give you any and all information concerning my current and previous employment and any pertinent information they may have, including disclosure of any disciplinary reports (even if more than four years old), and release all parties from any liability for any damages that may result from furnishing same to you. I further authorize you to release such information when such information may be requested by any prospective or subsequent employers without the need to provide me any notice of such disclosure.
  3. I understand that the use of this application does not indicate that there are positions available, nor does it imply or create an employment contract. I understand that the only employment contracts are those specifically authorized by Northpointe management that have been reduced to writing and have been executed by both the employee and an authorized representative of Northpointe. Accordingly, I understand that no employment contract, either expressed or implied, for any period, is created hereby should Northpointe hire me.
  4. If hired, I understand that my employment is at-will and can be terminated at any time, with or without notice, for any reason at the option of either Northpointe or me. Should Northpointe hire me, I agree to observe all Northpointe’s policies, practices, and procedures currently in existence and new and revised ones that may be issued in the future.
  5. I understand that any employment offer is conditional upon the result of the drug screening test, post offer pre-employment medical examination, and background investigation (when applicable based on position sought).
  6. I understand that if I have a physical, mental, or other impairment that would interfere with my ability to perform in a position but that may be accommodated by, for instance, the purchase of equipment or devices, the provision of readers, or interpreters, or the restructuring or altering of work schedules, the Michigan Persons With Disabilities Civil Rights Act requires me to notify Northpointe’s Human Resources Department in writing of need for accommodation within 182 days after I knew or should reasonably have known that the accommodation was needed.
  7. I agree that any lawsuit against Northpointe arising out of my employment or termination of employment, including but not limited to, claims arising under the State or Federal Civil Rights statutes, must be filed within six (6) months of the event giving rise to claims or be forever barred. I waive any limitations period to the contrary.
I HAVE READ, UNDERSTAND, AND AGREE TO THER TERMS OF EACH OF THE ABOVE SEVEN (7) INDIVIDUAL STATEMENTS, AS INDICATED ABOVE.


SIGNATURE:

DATE:



By checking this box I verify that this counts as a digital signature and all of my information is correct to the best of my knoledge. I also realize that I may have to sign a paper copy of this application prior to employment.

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