Application for Employment

Primary Position Applied For: * -- Select A Primary Position --Case Management Coordinator (P50-93-11)Clinical Quality Coordinator, QR (A10-98-11)Coder I (C08-59-11)Registered Nurse (P32-94-11)Registered Nurse (P08-94-12)Registered Nurse (P02-94-12)Registered Nurse (P35-94-10)

Second Position: -- Select A Second Position --Case Management Coordinator (P50-93-11)Clinical Quality Coordinator, QR (A10-98-11)Coder I (C08-59-11)Registered Nurse (P32-94-11)Registered Nurse (P08-94-12)Registered Nurse (P02-94-12)Registered Nurse (P35-94-10) (optional)

Third Position: -- Select A Third Position --Case Management Coordinator (P50-93-11)Clinical Quality Coordinator, QR (A10-98-11)Coder I (C08-59-11)Registered Nurse (P32-94-11)Registered Nurse (P08-94-12)Registered Nurse (P02-94-12)Registered Nurse (P35-94-10) (optional)

Status Desired: * Full-Time Part-Time   Both   Temporary Until

Date Available for Work:

Days Available for Full or Part-Time Work:

Whatever days job requires Sun Mon Tues Wed Thurs Fri Sat

Shift(s) Available: First (Days) Second (Evenings) Third (Nights) Any

Shift(s) Preferred: First (Days) Second (Evenings) Third (Nights) Any

Have you ever been employed by this organization? * No Yes   When?

Relatives Employed in this Organization:

Referred by (Current ZCH Employee): Last Name: First:

We offer equal opportunity employment to all individuals and do not discriminate on the basis of race, color, religion, national origin, sex, marital status, age, handicap, disability, height or weight, unless required to do so by law or bona fide occupational qualification. The questions on this application form are intended to be non-discriminatory in nature, and applicants are not required to submit any information which could be used for discriminatory purposes.

Full Name: *

Please indicate any other name you have had which would be required to check your work record:

Address Line 1: *

Address Line 2:

City, State, Zip: *

Home Phone:

Other Telephone:

Are you over 18 years of age? * No   Yes

Are you legally authorized to work in the United States? * No   Yes

Have you ever been convicted of a crime? * No Yes  

If Yes, when? Where? 

What was the nature of the offense?

Are there felony charges pending against you? * No   Yes

If yes, please explain:

You will not be refused employment solely because of a conviction of a crime. Rather, the organization's decision
 will be determined on whether the conviction relates in some way to the position applied for.

U.S. Military or Naval Service:   Rank upon discharge

Extracurricular activities:

List work training programs, seminars, extracurricular activities, or other educational experiences relevant to the position(s) applied for:

Currently taking course(s): Yes  No

Typing: (WPM)

Shorthand: (WPM)

Office, Hospital or Industrial Equipment Skilled to Operate:

Professional Licenses and/or Certificates

Has your license or certification ever been (voluntarily or involuntarily) or is in the process of being revoked, suspended, reduced, limited, placed on probation, not renewed, denied, loss of, non-renewal, previously successful or currently pending challenges or otherwise disciplined, or voluntarily relinquished for reasons other than relocation? Yes   No

If so, please provide a brief explanation:

Foreign Language Skills, including Signing: if required by, or helpful to, the position(s) applied for, please complete.

(List Last or Present Position First)

List all relevant experience, including paid employment, volunteer work or work in the U.S. Armed Forces.

Indicate any of the above employers you do not want us to contact:

List three references past or present (please do not list relatives): *

Upload your resumé file:

Please read carefully before submitting this Application.

I certify that all statements made on this application are true and that I have not knowingly withheld any fact or circumstances which would, if disclosed, affect my application.

I fully understand that the misrepresentation or omission of facts or circumstances will be sufficient cause for rejection of my application,if the Company has not employed me, and for immediate dismissal if the Company has employed me.

I authorize the investigation of all statements contained in this application and the further investigation of any the position(s) for which I am applying.

I authorize former employers, academic institutions, and other references to release any information required to determine my qualifications for the position(s) for which I am applying and hereby release all individuals and organizations from any liability or damages which may result from furnishing such information. I waive any right, under Public Act 397 of 1978, to receive written notice from this Company or former employers that such information has been released.

In consideration of my employment, I agree to conform to the policies and procedures of the Company and I also understand and agree that my employment and compensation is for no definite period and may, regardless of time and manner or payment of my wages and salary, be terminated at any time, with or without cause or notice, at the option of either the Company or myself. I also understand and agree that the Company has the right to unilaterally modify and/or terminate any policies, practices, procedures, and standards it has adopted or implemented to the extent not limited by law or contract. I acknowledge that no representative of the Company, other than the Chief Executive Officer or his/her designee, has either the power or authority to enter into any agreement for employment for any specified period of time, or to make any representations or agreements contrary to the foregoing, unless that agreement is in writing and signed by the Chief Executive Officer of the Company or his/her designee.

In consideration of Zeeland Community Hospital's review of my application, I agree that any claim or lawsuit arising out of my employment with, or my application for employment with, Zeeland Community Hospital or any of its subsidiaries must be filed no more than 180 days after the date of the employment action that is the subject of the claim or lawsuit. While I understand that the law may give me longer than 180 days to bring a claim or lawsuit, I agree to be bound by the 180-day period set forth herein, and I WAIVE ANY STATUTE OF LIMITATIONS TO THE CONTRARY.

I hereby acknowledge that I have read and understand the preceding statements. *
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