Employment Application For TCU at Hubbard - Transitional Care Unit

Merrimack Health Group, Inc., (MHG) - Marblehead, Massachusetts ( MA )

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Transitional Care Unit (TCU) at Hubbard Employment Application

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APPLICATION FOR EMPLOYMENT

The TCU is an equal opportunity employer. All qualified applicants will be considered without regard to age, race, color, sex, religion, national origin, marital status, ancestry, citizenship, veteran status, sexual orientation or preference, transgender status, physical or mental disability, genetic predisposition or carrier status, or any other category under applicable federal or state law.

This application must be completed in its entirety for consideration for employment.

E-MAIL ADDRESS

e-Mail Address:

CONTACT INFORMATION AND AND POSITION DESIRED

Name:
		(Last, First, Initial)

Present Address: (Street and Number) City: State: Zip Code:

Home Phone:

Work Phone:
May we contact you at work?

Cell Phone:

Position Applied For:

Note: If you do not remember the Job Code for the job your are applying, please use your browser back button to retrieve it.

Salary Range Desired:		Are you under 18 years of age?

GENERAL INFORMATION

List names of close relatives employed by The TCU:

Have you ever been employed by The TCU or any affiliate?

If yes, when and where?

How were you referred to The TCU?

Are you eligible to work in the United States?

All persons who are offered a position with The TCU will be required to present documentation which establishes their identity and eligibility for work in the United States.

EDUCATION

	Years Completed	School Name Location	Graduate Yes/No
High School

	Degree/ Certificate	Major	Honors/ Awards



	Years Completed	School Name Location	Graduate Yes/No
Technical School/ College

	Degree/ Certificate	Major	Honors/ Awards



	Years Completed	School Name Location	Graduate Yes/No
College/ University

	Degree/ Certificate	Major	Honors/ Awards



	Years Completed	School Name Location	Graduate Yes/No
Graduate Study

	Degree/ Certificate	Major	Honors/ Awards

Other Studies or Courses:

Special Training/Skills:

PROFESSIONAL LICENSES, REGISTRATIONS AND CERTIFICATIONS

Are you currently?
(Check all that apply)

Registered		Licensed		Certified		Eligible

Type of License/Certificate	License #	Control #	Expiration Date	State

Do you have any prior or pending actions against any of the clinical licenses you have had?

Do you have any pending actions against your professional license, even if it does not impact the status of your license?

Is your current professional license restricted in any fashion?

If so, how is your license restricted?

Do you hold a license, degree, certification or other credentials in a healthcare profession from a country outside of the U.S.?

If yes, what document, when was it awarded and from what country?

This information is used for workforce development purposes only.
This information is voluntary.

EMPLOYMENT HISTORY

(Please start with most recent employer.)

Applicants may include in this section any military experience as well as verified
work performed on a voluntary basis.

Do not merely state “Refer to resume.”

Current or Last Employer:
Address:
City:
State:
Zip Code:
Telephone No:

Supervisor Name:
Supervisor Title:
Supervisor Email:

Position/Title:

Position/Title Type:

Employment Dates (Mo/Yr):

Pay:

From:
To:

Starting Pay:
Ending Pay:

Reason for Leaving:

Brief Description of Job Duties:

May we contact this employer?

Name Employer:
Address:
City:
State:
Zip Code:
Telephone No:

Supervisor Name:
Supervisor Title:
Supervisor Email:

Position/Title:

Employment Dates (Mo/Yr):

Pay:

From:
To:

Starting Pay:
Ending Pay:

Reason for Leaving:

Brief Description of Job Duties:

May we contact this employer?

Name Employer:
Address:
City:
State:
Zip Code:
Telephone No:

Supervisor Name:
Supervisor Title:
Supervisor Email:

Position/Title:

Employment Dates (Mo/Yr):

Pay:

From:
To:

Starting Pay:
Ending Pay:

Reason for Leaving:

Brief Description of Job Duties:

May we contact this employer?

Name Employer:
Address:
City:
State:
Zip Code:
Telephone No:

Supervisor Name:
Supervisor Title:
Supervisor Email:

Position/Title:

Employment Dates (Mo/Yr):

Pay:

From:
To:

Starting Pay:
Ending Pay:

Reason for Leaving:

Brief Description of Job Duties:

May we contact this employer?

Have you ever been discharged by a previous employer or resigned after being told that
your performance was unsatisfactory?

If yes, please explain:

SKILLS

Please indicate languages you speak, read, and/or write and indicate level of fluency (fluent, good, fair)

	Language	Speak	Read	Write
1.
2.
3.

List computers, operating systems, and/or software with which you are familiar

Computers		Operating Systems		Software

REFERENCES

Please list three references whom we may contact concerning your qualifications

Name:
Company:
Title:
Telephone No.:

Persons employed at The TCU have access to confidential information regarding various phases of Company business. Therefore, the Company follows the usual practice of requiring new employees, at the time of employment to sign an Employee Confidentiality and Proprietary Information Agreement. Information concerning competitors' operations, or other proprietary information will not be solicited from you for employment, or from The TCU employees. The TCU will honor any valid employment restrictions you have with former employers.

DISCLOSURE

I certify that the above information is true, complete, and correct to the best of my knowledge. I represent that I have withheld nothing which, if disclosed, would affect this application unfavorably. I understand that any false statement, misrepresentation or omission made by me on my application, resume, or any other materials I have submitted, or during my interviews, can result in denial of employment, or, if I am already employed when such false statement, misrepresentation or omission is discovered, immediate termination of my employment. I understand that if employed, my continued employment will be subject to periodic performance evaluations.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

I understand that any offer of employment is conditioned upon satisfactory results of a medical examination by medical personnel selected by The TCU, to which I hereby consent. I also agree that, if I am hired, I will undergo medical examinations at such other times as may be required by The TCU during my employment.

I authorize The TCU to inquire into my educational, professional and past employment history references as needed to research my qualifications for this position, including performing a CORI criminal record check. I hereby give my consent to any former employer, educational institution, or individual listed as a reference in this application to provide information about me to The TCU, and I agree to hold the Company and any such former employer, educational institution, or individual harmless from any claims made by me on the institution, or individual and the institution or individual shall not be held liable in any respect if a job offer is not extended or is withdrawn by the Company or if my employment is terminated due to information provided in response to this application as part of the employment process.

I understand that the Immigration Reform and Control act of 1986 requires that, if hired, I must furnish appropriate documentation to The TCU establishing my identity and employment eligibility. If offered a position by the Company, I agree to provide the Company documents which verify my identity and right to work in the United States within 3 business days of commencing employment as a condition of my employment. The Company reserves the right to terminate the employment on any employee failing to produce satisfactory documentation within three (3) days.

I hereby give my consent to The TCU to perform the appropriate tests to identify the presence of drugs and alcohol.

I understand that during my employment with The TCU, I will be tested under the following circumstances:

Pre-employment - All new employees will be hired on condition of passing a drug and alcohol test. All applicants must sign a consent form before being considered for employment. Those under 18 years of age must have a consent form signed by a parent or legal guardian.

Post Accident –The TCU will make every effort to ensure that all persons involved in any work related accident that results in medical treatment beyond first aid, or that results in property damage of $500 or more, will be tested for use of illicit substances and alcohol.

Reasonable Cause – The TCU will require a drug and/or alcohol test of any person suspected of using or being under the influence of an illicit drug or alcohol. Reasonable cause testing will be initiated whenever it is believed, through observation of specific physical and/or behavioral symptoms, that an employee has used an illegal substance and/or abused a legal drug or alcohol. I furthermore give my permission for the test results to be released to The TCU. I understand that refusal to take any test, attempts to dilute or adulterate specimens, or conduct that in any way obstructs the collection process, will result in the termination of my employment and/or denial of my application for employment with The TCU.

I understand that employment at The TCU is terminable “at will” which means that the employment relationship can be terminated by either me or the Company at any time and for any reason not prohibited by law. I understand that nothing in this employment application, the granting of an interview for employment, any offer of employment, nor any personnel manuals or forms used by the Company creates an employment contract between me and the Company. I further understand that no supervisor, manager, or representative of the company other than the Chief Operating Officer has any authority to enter into any agreement for employment for any specified period of time.

I agree that if I am hired, I will sign all forms and associated HR-related agreements, attend all required orientations and complete all competency based assessments, etc. Failure to comply with these requirements may result in my termination.

In the event of my employment with The TCU, I agree to comply with all Company rules and regulations.

I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THE ABOVE DISCLOSURES AND ALL THE INFORMATION ON THIS APPLICATION AND I HEREBY AGREE AND CONSENT TO SUCH REQUESTS FOR INFORMATION AND OTHER ACTIONS WHICH THE COMPANY MAY TAKE, AS DESCRIBED HEREIN.

Date That You Acknowledge The Above Statement:

UPLOAD COVER LETTER AND RESUME

NOTE: Total combined size of files being submitted cannot exceed 700 KB.

Upload Cover Letter:

Microsoft Word or Adobe PDF Format Only
( .doc .docx .pdf )

Upload Resume:

Microsoft Word or Adobe PDF Format Only
( .doc .docx .pdf )

SUBMIT YOUR APPLICATION

Please note that all application information will be kept confidential
and will not be sold or released and will not be sold or released.
Please see our Privacy Policy for more information.

In addition, you will receive a copy of your application form via the e-mail address entered above.

Merrimack Health Group and TCU at Hubbard
are equal opportunity employers.

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PLEASE CLICK THE SUBMIT BUTTON ONLY ONCE

HR USE ONLY: Application Name:

Merrimack Health Group's facilities provide quality clinical care services
including the following:

		Orthopaedic
		Cardiac Pulmonary / Respiratory
		Wound Care
		Stroke
		Rehabilitation including:
		- Physical, Occupational, Speech

		I.V. Therapies
		Alzheimer's and Related Disorders
		Respite Care
		Hospice Care
		Gero-psychiatric Programs
		Post-Surgical Conditions

Please click here for a link to our facilities.

Merrimack Health Group, Inc., 25 Lafayette Street, Marblehead, MA 01945 Telephone: (781) 631-5057 Fax: (781) -631-3482	Legal – Privacy – Site Map Copyright© 2013. All rights reserved.
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