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Online Application

615 N. Promenade Street, Havana, IL 62644

Online Application

Online Application

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Personal Information

Any previous name(s)?

NoYes

Check all you would consider working:

Full Time/RegularFull Time/TemporaryPart Time/RegularPart Time/Temporary

Relatives or Friends employed in this facility?

NoYes

Have you ever been employed by this facility?

NoYes

Are you 18 yrs of age or older?

YesNo

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

YesNo

Would you consider working?

Weekends & Holidays

YesNo

Rotating Shifts

YesNo

On Call

YesNo

Any Shift

YesNo

Shift availability (check all that apply):

DaysEveningsNights

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?

NoYes

Have you been sanctioned, cited, reported, or excluded from participation in medicare, medicaid, or any other healthcare related law or regulation?

NoYes

Education / Skills

SCHOOL NAME AND ADDRESS OF SCHOOL COURSE OF STUDY CHECK LAST YEAR COMPLETED DID YOU GRADUATE? LIST DIPLOMA OR DEGREE
School 1234 YesNo
College 1234N/A YesNoN/A
College 1234 YesNo

Professional Licenses

Currently LicensedCurrently RegisteredEligible For LicenseEligible For RegistrationN/A

License Or Registration Ever Suspended, Revoked Or On Probation?

NoYes

Professional Certifications

Currently CertifiedEligible For CertificationN/A

Previous Experiences

Provide Information Regarding Previous Employment Beginning With Most Recent Employer.
Previous Experience 1
Previous Experience 2
Previous Experience 3
Previous Experience 4
Previous Experience 5
Previous Experience 6
Previous Experience 7
Previous Experience 8

May We Contact Your Current Employer?

YesNo

References

List At Least Three (3) Professional / Work/School References Who Are Not Relatives Or Personal Acquaintances
Reference 1
Reference 2
Reference 3

Signature / Submit

Carefully Read This Section Prior To Providing Signature Below

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 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 a written agreement signed by an administrative representative of this facility and notarized.