(618) 548-3194
• 1201 Ricker Drive Salem, Illinois 62881
Patients
Staff
Careers
Home
About
Leadership
Our History
Careers
Auxiliary
Foundation
Community
Speakers Bureau
Services
Cardiopulmonary Rehabilitation
Cardiopulmonary
Emergency Department
Inpatient Services
Laboratory
Outpatient Nursing Clinic
Therapy Services
Radiology
Rural Health Clinic
Sleep Lab
Specialty Clinics
Surgery
Providers
Patients
Visitors
News & Events
Wellness & Prevention
Resources
Contact
Cafeteria & Bistro
Contact
Employee Benefits
Employment Application
Home
Hospital Charges
News & Events
Patients
Resources
Slider-Test
Standards of Behavior
test application
Visitors
Welcome
Wellness & Prevention
test application
Online Employment Application
Last Name
*
First Name
*
Middle
Phone
*
Street Address
*
City
*
State
*
Zip Code
*
Email
*
Best Contact Time
Date Available for Work
Previous Name(s)?
Please identify including maiden name.
Position Applied for:
Salary Desired:
Reference
Newspaper
Internet
Friend
Other
Are you a U. S. Citizen or an alien legally authorized to work in the U. S.?
*
Yes
No
Shift Availability
Days
Evenings
Nights
Would you consider:
Any Shift
Weekends & Holidays
On Call
Day Shift
Evening Shift
Have you ever been employed by this facility?
*
Yes
No
Would you consider:
Full Time (72-80 hours every 2 weeks)
Part Time (30-72 hours every 2 weeks)
Less than Part Time (less than 30 hours every 2 weeks)
PRN/Float Pool (used to fill in as needed)
Are you 18 years of age or older?
*
Yes
No
Relatives/Friends Employed?
List Name, Department, Relationship
Long Range Occupational Goals:
High School Name and Address
*
Diploma/GED
Did you graduate High School?
*
Yes
No
College/University Name & Address
College Degree(s)
Did you graduate from College?
Yes
No
Areas of Specialization or Major Interest:
Other Business College or Special Courses (Include Special Military Training, Post Graduate and Nursing):
List Office Skills including Computer/Software Experience (Include Word Processing, approximate WPM):
List Health Care, Business or Industrial Equipment Operated:
Professional License (List Type, State, No., and Date):
License Status
Currently Licensed
Currently Registered
Eligible for License
Eligible for Registration
License or Registration Ever Suspended, Revoked or on Probation?
Yes
No
Please explain any Suspension, Revokation or Probation:
Additional Professional License (List Type, State, No., and Date):
Additional License Status
Currently Licensed
Currently Registered
Eligible for License
Eligible for Registration
License or Registration Ever Suspended, Revoked or on Probation?
Yes
No
Please explain any Suspension, Revokation or Probation:
Professional Certification (List Type, State, and Date):
Certification Status
Currently Certified
Eligible for Certification
Additional Certification (List Type, State, and Date):
Additional Certification Status
Currently Certified
Eligible for Certification
Briefly describe Duties and Skills acquired through Military or Volunteer Service: (Include Dates)
Job Title
From: (Mo/Yr)
To: (Mo/Yr)
Salary (hr/mo/yr)
Employer Name
Employer Address
Employer Phone
Supervisor Name
May We Contact?
Yes
No
Duties
Reason for Leaving
Job Title
From: (Mo/Yr)
To: (Mo/Yr)
Salary (hr/mo/yr)
Employer Name
Employer Address
Employer Phone
Supervisor Name
May We Contact?
Yes
No
Duties
Reason for Leaving
Job Title
From: (Mo/Yr)
To: (Mo/Yr)
Salary (hr/mo/yr)
Employer Name
Employer Address
Employer Phone
Supervisor Name
May We Contact?
Yes
No
Duties
Reason for Leaving
Job Title
From: (Mo/Yr)
To: (Mo/Yr)
Salary (hr/mo/yr)
Employer Name
Employer Address
Employer Phone
Supervisor Name
May We Contact?
Yes
No
Duties
Reason for Leaving
Reference Name
*
Non-Relatives Only
Company Name and Title/Position
*
Company Phone Number & Address
*
Reference Name
Non-Relatives Only
Company Name and Title/Position
Company Phone Number & Address
Reference Name
Non-Relatives Only
Company Name and Title/Position
Company Phone Number & Address
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:
Date and Name (E-Signature)
*
Carefully read this section prior to providing signature. I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions made on the application or during the hiring process may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date. I understand that employment may be conditioned upon successfully passing a medical examination and that I may be required to satisfactorily complete a drug screening as a condition of employment. I hereby authorize persons, schools, my current employer (if applicable) and previous employers and other organizations to provide this facility and its affiliates with any requested information regarding my application or suitability for employment, and I completely release all such persons or entities from any and all liability related to the providing or use of such information. I understand that my employment is at-will which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that the facility has the same right. I understand that no one has the authority to enter into any agreement contrary to the preceding sentence, except for written agreement signed by an administrative representative of this facility and notarized.