Employment Application

Mercy Hospital - Valley City - Employment Application

Name * Title First Last Suffix
Position(s) applying for?
Date of Application / MM / DD YYYY
How did you learn about us?
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
Email
Best time to contact:
Employment questions Are you at least 18 years of age? If not, can you provide required proof of work eligibility? Have you ever filed an application with us before? Do any of your friends or relatives, other than spouse, work here? Are you currently employed? May we contact your present employer? Are you a U.S. citizen, or have legal status? Are youcurrently on "lay-off" status and subject to recall? Can you travel if required?
Date available / MM / DD YYYY
What is your desired salary range?
Work load status Full time Part time Temporary
Shift preference Morning Afternoon Evening Overnight
Education
High School Education:
Name of High School, city, and state.
College Education:
List places of secondary education, dates, programs of study, and cities located.
Graduate programs:
List all graduate programs takes, universities attended, dates, and cities located.
Other education:
List other education information, including certifications, etc.
Specialized training:
Describe any specialized training, apprenticeships, skills, and extra-curricular activities.
Military training:
Describe any job-related training received in the United States military.
Experience
Employer 1:
Enter your current employer's information.
Employer 1:
Job Title
Employer 1:
Reason for leaving
Employer 1:
Dates Employed
Employer 1:
Summary of work performed
Employer 2:
Enter the employer's information.
Employer 2:
Job Title
Employer 2:
Reason for leaving
Employer 2:
Dates Employed
Employer 2:
Summary of work performed
Employer 3:
Enter the employer's information.
Employer 3:
Job Title
Employer 3:
Reason for leaving
Employer 3:
Dates Employed
Employer 3:
Summary of work performed
Profession, trade, business or civic activities and offices held
Upload resume
Additional information
Other qualificiations:
Summarize any job related skills and qualifications acquired from other experiences.
Specialized skills:
List any computer, software, technical, or equipment skills.
Additional information:
State any additional information you feel may be helpful.
Job duties Have you been informed of the job duties and requirements? Are you capable of performing those duties in a reasonable manner?
Reference 1:
List information for a reference, including name, address, and phone number
Reference 2:
List information for a reference, including name, address, and phone number
Reference 3:
List information for a reference, including name, address, and phone number
Reference Authorization and Release
I voluntarily and knowingly authorize any former employer, person, firm, corporation, school or government agency, its officers, employees and agets to release any and all information concering my former employment to Mercy Hospital, its officers, employees and agents, or any other person or entity making a written or oral request for such information. I understand that the employment information may include, but is not necessarily limited to, performance evaluation and reports, job descriptions, disciplinary reports, letters or repriman, and opinions regarding my suitability for employment possessed by it.

I voluntarily and knowingly, fully release and dischard, absolve, indemnify and hold harmless such former employer, person, firm, corporation, school or government agency, its officers, employees, and agents from any and all claims, liability, demands, causes of action, damages, or costs, including attorney's fees, present or future, whether known or unknown, anticipated or unanticipated, arising from or incident to the disclosure or release except for the malicious and iwllful disclosure of derogatory facts concerning my employment made for the express purpose of preventing me from obtaining employment which the officer, employee or agent disclosing such facts knows are untrue.
Type name to authorize release * First Last
Release date * / MM / DD YYYY
Questions Have you ever been convicted of, or pled guilty or no contest to, a felony, misdemeanor, or any offsense other than a minor traffic violation? Are any criminal charges now pending against you? Have you ever participated in a first offender, deferred adjudication, or other program or arrangement where judgment or conviction has been withheld? Has any action been taken against you that excludes or has excluded you from participation in any federal government health care program, including Medicare? Have you ever had any professional registration license, or certification suspended or revoked? Have you ever informally resolved any recommended or potential adverse action involving your professional registration, license, or certification? Are any professional registration, licensure, or certification actions now pending against you? Have you ever been named as a defendant in any civil legal action involving your professional competence?
Checking a box will indicate a "YES" answer.
Please explain any "checked" answer(s):
All job offers are contingent upon review of references, background checks, OIG Exlucded Providers, and other relevant information. Any misleading or incorrect statements, omissions or failure to disclose any health care related criminal conviction or any threatened or actual debarment, exclusion or other ineligibility of participation infederally funded health care programs may remove this application from further consideration for employment and, if employed, may be causefor termination.

A conviction will not necessarily disqualify you from consideration; however, failure to fully and truthfully disclose will result in immediate denial or termination of employment.
I certify that answers given herein are true and complete.
I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.
This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment ebyond this time period should inquire as to whether ro not applications are being accpeted at that time.
I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will" nature, which means that hte Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is furth understood that this "at will" employment relationship may not be changed by any wirtten document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.
In the event or employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.

In agreeing to this statement, type your name and date in the below fields.
Name * First Last
Date * / MM / DD YYYY

Employment Application

Employment Application

Education

Experience

Additional information

Reference Authorization and Release