Apply Now! - Gogebic Medical Care Facility

Step 1 of 11

Military Service
Service
Branch
Date of Service
Date of Service
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Reserve Status

Employment History
List and explain any periods of unemployment. Please answer all inquires. "See Resume" is not acceptable.
Add Positions
Employer's Name
Date Started
Date Ended
Address
Street Address Address Line 2 City State ZIP Code

Telephone
Supervisor (Name & Title
Your Title
Salary
Duties & Responsiblities
Reason for Leaving
May we contact your present/past employer(s) for a reference?*
- Yes
- No
Have you ever been discharged by an employer or resigned in lieu of discharge?*
- Yes
- No
Have you even been disciplined (other than discharged) by an employer*
- Yes
- No
If you answered yes to either of the two previous questions, explain all such incidents, giving facts, dates, describing any action you took and any resolution.
How much time have you missed from work in the past twelve months?*
Do you have a valid Driver's License or State ID?*
- Driver's License
- State ID Card
- None
Driver's License or ID Number
State Issued

Education
School
Location
Degree
High School
High School Location
Address Line 2
High school (Proof of HS Diploma or GED required.)
- HS Diploma
- GED
Business School
Business School Location
Address Line 2
Business School Degree Type
College/University
College/University Location
Address Line 2
Degree Type
Trade/Vocational School
Trade/Vocational Location
Address Line 2
Degree Type
Extracurricular activities & honors reveived in school

Professional Licenses, Registrations, And/Or Certifications
List all states in which you are or have been licensed or certified and any additional certifications*
Attach copies of licenses and certifications. Copies of all licenses are required. Copies can also be faxed to 906-224-1213.
Drop files here or

Accepted file types: pdf, doc, docx, jpg, png, pdf, xls, xlsx.
Have you ever had any professional license or certification placed under investigation, disciplined, suspended, revoked or put on probation?*
- Yes
- No
If you answered yes to either above questions, explain in detail on an attached signed statement.

Miscellaneous
Do you have any felony charges pending against you?*
- Yes
- No
Have you ever been convicted or pled guilty or nolo contendere to a crime?*
- Yes
- No
If you answered yes to either of the two procedding questions, explain by giving the date, nature of the offense and circumstances in an attached, signed statement. Conviction of a crime will not necessarily disqualify an applicant form employment.
Are you 18 year of age or older?*
- Yes
- No
Are you able to perform the duties of the job for which you have applied?*
- Yes
- No
References: Give the name, address and telephone number of three references who are not related to you:*

Certification

I understand that i may be required to submit to a physical examination, which may include a drug test, prior to beginning employment and that i must satisfactorily pass such an examination to obtain employment.

I have read out fully understand the questions on this application for employment. I have completely, truthfully, and accurately answered each and every question to the best of my knowledge.

I understand that all the inquiries on this application are subject to verification and authorize any schools that i have attended, licensing and cetification boards and current and previous employers and current and previous to provide Gogebic Medical care Facility, with any requested information.

I also specifically waive wirtten notice from any and all former employers regarding their disclosure to Gogebic Medical Care Facility of any prior disciplinary action and waive my claim against Gogebic Medical care Facility and current or former employers arising from such investigation or disclosure.

I understand that any misrepresentation of the information i have supplied of failed to supply can result in a rejection of this application or, if i have been hired, immediate dismissal at the sole discretion of Gogebic Medical Care Facility.

I further understand and agree that if i am hired, unless I am covered by a written agreement to the contrary, signed by me or on my behald by my authorized representative, that my employment may be termined, either by me or by Gogebic Medical care Facility, at any time, with or without notice or cause. I

It is with this full understanding of Gogebic Medical Care Facility's exclusive right to make such discharge decisions, that i will accept any employment offered to me.
Electronic Signature*
Please type first and last name
*
- AGREEMENT: By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, refute the meaning of my electronic signature or claim that my electronic signature is not legally binding.
Date*
Date Format: MM slash DD slash YYYY

Authorization to Release Information
I hereby authorize Gogebic Medical Care Facility to conduct any necessary and reasonable investigation, with respect to my application, of past and present work, military service, character, and police records to determine any and all information, excluding medical information, which is or may be, pertinent to my qualifications for employment.

I hereby authorize you to provide any and all information, of record, and release you, Gogebic Medical Care Facility and all persons, agencies, companies, and firms from any damages that may result from providing such information.
Electronic Signature*
Please type first and last name
*
- AGREEMENT: By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, refute the meaning of my electronic signature or claim that my electronic signature is not legally binding.
Date*
Date Format: MM slash DD slash YYYY
Last four digits of Social Security Number*

GOGEBIC MEDICAL CARE FACILITY REGISTRY VERIFICATION RECORD
This form must be completed by all applicants, contractor, persons applying for volunteers, etc. regardless if they are licensed or not.
NAME (First, Middle and Last Names)*
First Middle Last
Maiden Name and/or Other Names Previously Used
County Currently Living In*
Nature of License: (RN, LPN, CNA, Etc.)*
Issuing State
State / Province / Region
Date of Issue
Date Format: MM slash DD slash YYYY
License/Certificate Number*
Have you worked in Long Term Care prior to April 1, 2006?*
- Yes
- No
As a perspective employee / trainee / volunteer of the Gogebic Medical Care Facility, I undemtand that the above information is required by the Facility in order to employ/train me in a licensed or certified position.

I authorize the Facility to utilize the above information, for sole purpose of verifying the employable / trainable status of my license (if applicable) with the Michigan, Wisconsin, or any other State Registry.
Electronic Signature*
Please type first and last name
*
- AGREEMENT: By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, refute the meaning of my electronic signature or claim that my electronic signature is not legally binding.
Date*
Date Format: MM slash DD slash YYYY

GOGEBIC MEDICAL CARE FACILITY SKILLS AND QUALIFICATIONS
Summarize special skills and qualifications acquired from employment or other experiences that may qualify you for the position for which you are applying.
List Skills and Qualifiations

GOGEBIC MEDICAL CARE FACILITY

Certification / Consent for Post-Employment Screening

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge. I also agree that any false information, representations or omissions may disqualify me from further considerations for employment and may result in discipline or dismissal if discovered at a later date.

Before I can begin work, and as a post-condition of employment, I understand I must be able to verify, as required by federal law, that I am authorized to work in the United States. I understand that all applicants offered a position at GMCF must document their authorization to work before the hiring process will be complete. If selected for hire, I understand it will be my responsibility to provide GMCF with documentation establishing my right to work. I understand these documents will be reviewed at the time a conditional offer of employment is made.

I authorize a thorough investigation of my past employment and education, including discipline records, and agree to cooperate in such investigation. I release from all liability and responsibility all persons, corporations and/or educational institutions requesting or supplying such information and waive any right to notice of such disclosure.

I understand that part of GMCF's screening process will include a search of criminal history and convictions and a criminal history check to verify information provided by me during the application process. As a part of this investigation, I may be required to provide my date of birth, sex, driver's license, and state of issue. I understand that this information is required to facilitate this investigation. My signature below signifies that I understand and agree to authorize GMCF to secure criminal history convictions from the appropriate law enforcement agency.

I agree to submit to any physical testing and a urine drug screen which may be necessary to determine my ability to perform the job for which I am being considered. I further authorize any physician or entity conducting such medical examination to release the results of such examination to GMCF.
<>.I understand that if I am granted an interview, I will be asked at that time if I can perform the essential functions of the job for which I am applying, with or without reasonable accommodation. I also understand that if I have protected disability that affects my ability to do the job I seek, I may ask GMCF to attempt to make a reasonable accommodation for it. Under federal law, it is my responsibility to inform GMCF that accommodation is needed. I understand I must take my request for accommodation in writing to the Personnel Supervisor as soon as possible. Under state law, such request must be made no later than 182 days after the date I know or reasonably should know that a accommodation is needed.

If hired, in consideration of my employment, I agree to abide by the rules and policies of GMCF. I understand that my employment with GMCF is for an indefinite term, and I am subject to termination at any time with or without notice, with or without discipline or warning, and with or without cause. No person other than the Administrator of GMCF has the authority to offer employment for any specified periods of time or make any contract contrary to the foregoing. Moreover, no such agreement by the Administrator shall be enforceable unless it is in writing, pertains specifically to me, and is signed by the Administrator of GMCF.
Electronic Signature*
Please type first and last name
*
- AGREEMENT: By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, refute the meaning of my electronic signature or claim that my electronic signature is not legally binding.
Date*
Date Format: MM slash DD slash YYYY

Step 1 of 11

Application for Employment

Gogebic Medical Care Facility

Military Service

Employment History

Education

Professional Licenses, Registrations, And/Or Certifications

Miscellaneous

Certification

Authorization to Release Information

GOGEBIC MEDICAL CARE FACILITY REGISTRY VERIFICATION RECORD

GOGEBIC MEDICAL CARE FACILITY SKILLS AND QUALIFICATIONS

GOGEBIC MEDICAL CARE FACILITY

Certification / Consent for Post-Employment Screening