First Name

Middle Name

Last Name

Any previous name(s)?   Yes   No

If Yes, identify all other names including Maiden name.

Present Address

Street Address

City

State

Zip Code

Permanent Address

Street Address

City

State

Zip Code

Home Phone
- -
Contact Phone
- -
Best Time To Contact You

Email

Date Available for Work

 

Personal Information

Position Applied For:

Salary Desired:

How did you learn about this position? (Newspaper, internet, friend, etc.)

Relatives or friends employed in this facility?  

Yes    No

If yes, their name:

Department:

Relationship:

Have you ever been employed by this facility?

Yes    No

If yes, when?

Are you 18 yrs. of age or older?

Yes    No

Are you a U.S. citizen or an alien legally authorized to work in the United States?

Yes    No

Long range occupational goals:

Have you ever been convicted of, or plead guilty to, a crime other than a misdemeanor traffic violation?

Yes    No

 

If yes, which state(s), and explain (you are not required to disclose any SEALED or EXPUNGED criminal records):

Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this or any other state of the United States?

Yes    No

 

If yes, which state(s), and explain:

Have you been sanctioned, cited, reported, or excluded from participation in Medicare, Medicaid, or any other Healthcare related law or regulation?

Yes    No

 

If yes, explain:

 

Would you consider working:

Check all you would consider working:

 Full Time / Regular   

 Full Time / Temporary 

 Part Time / Regular  

 Part Time / Temporary 

Weekends & Holidays

Yes    No

Rotating Shifts

Yes    No

On Call

Yes    No

Any Shift

Yes    No

Shift availability (Check all that apply):

Days   Evenings   Nights

 

Education / Skills

High School

Address of high school:

Course of study:

Check last year completed:

1  2  3 

List diploma or degree:

College 1

Address of college:

Course of study:

Check last year completed:

1  2  3  4

List diploma or degree:

College 2

Address of college:

Course of study:

Check last year completed:

1  2  3  4

List diploma or degree:

Other Business College or Special Courses (Include special military training, post graduate and nursing):

Area(s) of specialization or major interest:

List office skills including computer/software experience:

List health care, business, or industrial equipment operated:

Word processing (Approx. WPM)

Professional Licenses

Currently Licensed 

Eligible for Licensed 

Currenty Registered

Eligible for Registration 

Type:
No:
State:
Date:

Has your license or registration ever been suspended, revoked or on probation?

Yes    No

If yes, explain:

Professional Licenses

Currently Licensed 

Eligible for Licensed 

Currenty Registered 

Eligible for Registration 

Type:
No:
State:
Date:

Has your license or registration ever been suspended, revoked or on probation?

Yes    No

If yes, explain:

Professional Certifications

Currently Certified  Eligible for Certification 

Type:
State:
Date:

Professional Certifications

Currently Certified  Eligible for Certification 

Type:
State:
Date:

 

Previous Experience

Briefly descirbe duties and skills acquired through military or volunteer service (include dates):

Job Title

Start Date (Mo/Yr) - End Date (Mo/Yr)
Employer Name
Address
Phone
- -

Job Duties

Supervisor's Name

Salary (Hr/Mo/Yr)

Reason for leaving:

Job Title
Start Date (Mo/Yr) - End Date (Mo/Yr)
Employer Name
Address
Phone
- -
Job Duties
Supervisor's Name
Salary (Hr/Mo/Yr)
Reason for leaving:
Job Title
Start Date (Mo/Yr) - End Date (Mo/Yr)
Employer Name
Address
Phone
- -
Job Duties
Supervisor's Name
Salary (Hr/Mo/Yr)
Reason for leaving:
Job Title
Start Date (Mo/Yr) - End Date (Mo/Yr)
Employer Name
Address
Phone
- -
Job Duties
Supervisor's Name
Salary (Hr/Mo/Yr)
Reason for leaving:
Please identify and explain any gaps in employment longer than three (3) months:

 

Language Skills

Do not complete unless requested.

Language
Do you Speak
If so, Fair    Good    Fluent
Do you Read
If so, Fair    Good    Fluent
Do you Write
If so, Fair    Good    Fluent
Language
Do you Speak
If so, Fair    Good    Fluent
Do you Read
If so, Fair    Good    Fluent
Do you Write
If so, Fair    Good    Fluent

 

References

Name and Relationship
Title
Company name and address
Telephone
Name and Relationship
Title
Company name and address
Telephone
Name and Relationship
Title
Company name and address
Telephone
Name and Relationship
Title
Company name and address
Telephone

St. Margaret’s Hospital

600 E. First Street
Spring Valley, IL 61362

 

Hospital Operator:

(815) 664-5311 or (815) 223-5346

(815) 664-1578 TTY

 

Email:

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