Grace Health

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Personal Details

Full Name*

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Email Address*

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Phone Number*

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Address

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Experience

Work History*

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Education*

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Experience Summary*

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Cover Letter*

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  • Complete Address*

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  • Are you under the age of 18?*

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  • What is your preferred method of contact?*

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  • How did you hear about employment opportunities at Grace Health?*

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  • Have you been convicted of a crime (felony or misdemeanor) which has not been annulled, expunged, or sealed by a court?*

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  • If so, when?*

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  • What was the nature of the crime?*

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  • Are there any charges pending against you?*

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  • Salary preferred*

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  • Have you ever applied to Grace Health before?*

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  • Have you ever been employed by Grace Health before?*

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  • If so, when?*

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  • What is your desired status?*

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  • Are there any hours or days you cannot or will not work?*

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  • If so, when?*

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  • Are you a U.S. Citizen or otherwise authorized to work in the U.S. on an unrestricted basis?*

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  • Can you perform, with or without reasonable accommodation, all essential functions of the position for which you are applying?*

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  • Do you have two or more years of experience as a provider?*

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  • Professional License and/or Certification*

    Please list the type of license, license number and expiration date. 

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  • Have you ever surrendered or had a state professional license and/or certification revoked, suspended, denied, restricted, placed on probation or placed under other disciplinary action?*

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  • Is any such action pending?*

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  • Are there any formal complaints against your license and/or certification?*

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  • May we contact your present employer(s)?*

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  • Certification and Agreement Signature*

    I authorize the investigation of all statements contained in this application and the further investigation of any information required to determine my qualifications for the position(s) for which I am applying. The purpose of pre-employment investigations is to verify and update information you have provided in this application and in interviews. We may verify information such as driving record, previous and current employment history, college degrees granted, certifications and licenses claimed, and/or any other information provided.

    We may order a report or reports considered “Consumer Reports” under the Federal Fair Credit Reporting Act. An example is a Motor Vehicle (MVR) from the state department of motor vehicles. In accordance with the Federal Fair Credit Reporting Act, Grace Health will provide you with information about the reporting organization should anything revealed in those reports cause Grace Health to take a negative action regarding your application for employment. I authorize former employers, schools, 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 Grace Health of former employers that such information has been released.

    I fully understand the misrepresentation or omission of facts or circumstances will be sufficient cause for the cancellation of my consideration for employment or cause for termination if I have been employed.

    Should I require accommodation for a disability, it is my responsibility to request it in writing within 182 days after I know or reasonably know it is required.

    I understand and agree I will be required to complete a drug screen and background check, and may be required to complete a physical examination.

    Grace Health is an equal opportunity employer. As required by the Immigration Reform and Control Act, Grace Health cannot employ you unless you can produce work authorization and identity documents as specified by the law. If you have questions, you should discuss this with a Human Resources representative.

    I understand employment at Grace Health is “at will”, which means either I or Grace Health can terminate the employment relationship at any time, with or without prior notice and for any reason not prohibited by statute. All employment is continued on that basis. I understand that no supervisor, manager, or executive of Grace Health, other than the President/CEO has authority to alter the foregoing, which must be done in writing.

    By signing my name below I certify all statements made on this form are true and I have not knowingly withheld any fact or circumstance which would, if disclosed, affect my application unfavorably.

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We're an equal opportunity employer

You are requested (not required) to complete the personal data below. This information will only be used for government reporting purposes and not as selection criteria for our hiring process.

  • Race or Ethnicity

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  • Gender

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