Employment Application

Employment Application

Background Check

This employment applicant information is required to process a complete and accurate criminal record check.

Previous Employment

Education & Experience

Professional License(s)/Certification(s)

Applicant Disclosure Statements

MCL 333.20173a, MCL 330.1134a, and MCL 400.734b, subsections (1)(a) through (g) describe crimes for which a conviction during the applicable time period will disqualify a person from being employed by, independently contracting with, or being granted clinical privileges in a covered health care facility/agency or AFC.
The above laws define “conviction” as, “... a final conviction, the payment of a fine, a plea of guilty or nolo contendere (no contest) if accepted by the court, or a finding of guilt for a criminal law violation or a juvenile adjudication or disposition by the juvenile division of probate court or family division of circuit court for a violation that if committed by an adult would be a crime.” For relevant crimes described under 42- USC 1320a-7(a), convicted means that term as defined in 42-USC 1320a-7. These definitions may include cases that resulted in an alternative sentencing agreement, including deferred or delayed sentences, and for relevant crimes under 42-USC 1320a-(7)(a), convictions which may have been expunged or set aside.

If you are not able to certify a, b, or c above, please explain below:


Please list at least 3 references, other than relatives and previous employers, whom you have known for at least 1 year

Application Submission