Application: Primary Care Physician Job at Gerald L. Ignace Indian Health Center, Inc. in Milwaukee, WI

Contact phone number

Level of education attained

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Please take the time to answer the following questions.
Questions in black are optional and questions in red are required.

Q1. Explain related experience and education to the position you are applying for:

Q2. Are there any days, shifts or hours you will not work?*

*Note: It is not necessary for you to identify unavailability for work because of religious observance or
practice or any other protected classification. Subsequent to any job offer, we will consider whether a
reasonable accommodation can be made.

Yes
No

Q3. If you answered yes, please explain:

Q4. Will you work overtime, if required?*

*Note: It is not necessary for you to identify unavailability for work because of religious observance or
practice or any other protected classification. Subsequent to any job offer, we will consider whether a
reasonable accommodation can be made.

Yes
No

Q5. How did you learn of our Company?

Q6. Have you ever applied or worked at our Company before?

Yes
No

Q7. Are you legally authorized to work in the United States?

Note: The Federal Immigration and Reform and Control Act of 1986 requires that a DHS
Employment Eligibility Verification “Form I-9” be completed for every new hire and that within 3
business days of beginning work every new hire must present to the employer documentation
establishing his/her identity and authorization to work. This federal requirement must be satisfied as
a condition of employment.

Yes
No

Q8. Will you now or in the future require sponsorship for employment visa status (e.g.,H-1B visa status)?

Yes
No

Q9. Name of current employer

Q10. May we contact your current employer?

Yes
No

Q11. Name of current supervisor:

Q12. Job titles and job responsibilities:

Q13. Date of employment for current employer:

Q14. Reason for leave current employer:

Q15. Name of past employer (2):

Q16. May we contact your past employer (2)?

Yes
No

Q17. Name of past supervisor (2):

Q18. Job titles and job responsibilities (2):

Q19. Dates of employment for past employer (2):

Q20. Reason for leaving past employer (2):

Q21. Name of past employer (3):

Q22. May we contact your past employer (3)?

Yes
No

Q23. Name of past supervisor (3)?

Q24. Job titles and job responsibilities (3):

Q25. Dates of employment for past employer (3):

Q26. Reason for leaving past employer (3):

Q27. APPLICANT’S ACKNOWLEDGMENT

I certify that the answers given herein and during the entire application process (including but not limited to information provided in resumes, attachments to this application, interviews or otherwise (if applicable)) are true and complete to the best of my knowledge.

I understand that any misrepresentations, omissions of facts or incomplete answers during the application process may disqualify me from further consideration for employment. I further understand that, if employed, any misrepresentations or omissions of facts during the application process may be cause for my dismissal at any time without prior notice.

I consent to and authorize the Company to contact my former employers, references, and any and all other persons and organizations for information bearing upon my qualifications for employment.

I further authorize the listed employers, schools and personal references to give the Company (without further notice to me) any and all information about my previous employment and education, along with any other pertinent information they may have and hereby waive any actions which I may have against either party(ies) for providing a good faith reference.

I EXPRESSLY AGREE AND UNDERSTAND THAT, IF EMPLOYED, MY EMPLOYMENT IS NOT FOR A SPECIFIC TERM, IS BASED ON MUTUAL CONSENT AND MAY BE TERMINATED BY ME OR THE COMPANY WITH OR WITHOUT NOTICE OR CAUSE AT ANY TIME. I FURTHER UNDERSTAND THAT NO ORAL PROMISE, EMPLOYER POLICY, CUSTOM, BUSINESS PRACTICE OR OTHER PROCEDURE (INCLUDING PERSONNEL HANDBOOK OR ANY PERSONNEL MANUALS) CONSTITUTE AN EMPLOYMENT CONTRACT OR MODIFICATION OF THE AT-WILL EMPLOYMENT RELATIONSHIP BETWEEN ME AND THE COMPANY. I ALSO UNDERSTAND THAT MY AT-WILL EMPLOYMENT STATUS WITH THE COMPANY MAY ONLY BE ALTERED IN AN INDIVIDUAL CASE OR GENERALLY IN A WRITING SIGNED BY THE OWNER, PRESIDENT OR CEO OF THE COMPANY.

I understand I may be required to qualify for employment based on additional employment criteria. For example, I may be required to take job-related tests; take a driver’s examination or take a pre-employment drug test. If I am offered employment or start work before any required test is completed, I understand that my employment is contingent on a satisfactory result on all required tests. I authorize the release of any drug/alcohol test to any state or federal authority requesting such information and in response to a valid subpoena or other legal document. I agree to sign any additional forms necessary for drug tests to be conducted.

CALIFORNIA APPLICANTS ONLY: I understand the Company may obtain, without using the services of a third party investigative consumer reporting agency, public records pertaining to my character, general reputation, personal characteristics or mode of living during its evaluation of my application for employment and, if employed, during my employment. By checking the following box, I waive my right to receive copies of public records obtained by the Company.

California Applicants: By checking the following box, I waive my right to receive copies of public records obtained by the Company.
Acknowledgement and verification of Application

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