job application | Sarah Bush Lincoln

PERSONAL INFORMATION

Position you are applying for: *

First Name: *

Middle Name:

Last Name: *

Previous Names:

Address: *

City: *

State: *

Zip: *

Home Phone:

Cell Phone: *

Email: *

Are you eligible for employment in the United States? *

Yes
No

Have you ever been employed by SBL Fayette County Hospital? *

Yes
No

Are you willing to complete a post-offer physical which includes a drug screen for illegal drugs? *

Yes
No

Do you have limitations that would affect your ability to perform the essential functions of the position? *

Yes
No

Are you a current employee of SBL Fayette County Hospital? *

Yes
No

What shifts are you willing to work? *

Day
Evening
Night
Any

What employment status are you most interested in? *

FT
PT
PRN
Any

What is your second choice of shifts you are willing to work? *

Day
Evening
Night
Any

What is your second choice of employment status? *

FT
PT
PRN
Any

EDUCATION

High School:
Please list name of school, location, and degree

Years attended:

College/University:
Please list name of school, location, and degree

Years attended:

Business/Trade School:
Please list name of school, location, and degree

Years attended:

Professional School:
Please list name of school, location, and degree

Years attended:

Other Training:

EMPLOYMENT INFORMATION

Please provide complete work history information. Accurate compensation offers are based on applicable experience and education.

Current Employer (if any):

Job Title:

Start Date:

End Date:

Reason for leaving:

Job Responsibilities:

Contact:

OK to contact:

Yes
No

Phone:
Enter Ext

Email:

City / State / Zip:

Previous Employment

Previous Employer:

Job Title:

Start Date:

End Date:

Reason for leaving:

Job Responibilities:

Contact Name:

Ok to contact:

Yes
No

Phone & Ext.

Email:

City / State / Zip:

REFERENCES

Please provide at least two professional references.

Name:

Phone:

Relationship:

Name:

Phone:

Relationship:

How did you hear about us:

Other:
if "Other" was selected, please share

If you selected "Employee", would you like to share the name:

We are required to compile the following information for statistical purposes in order to fulfill certain federal regulations relating to Equal Employment Opportunity and Affirmative Action requirements. The information you provide is strictly voluntary, and the content of the information will not affect your eligibility for employment. Similarly, if you choose not to provide this information it will not affect your eligibility for employment.

Please select veteran status: *

Not Applicable
Active
Retired

In submitting this application for employment, I understand that an inquiry may be made whereby information is obtained regarding my character, previous employment, general reputation, education, educational background and/or driving record. I attest that the information in this application is complete and accurate to the best of my knowledge. I authorize inquiry of all statements contained in this application and do hereby release and all persons, companies or agencies responding to such an investigation from any and all liability for damage due to releasing information pertaining hereto. Any misrepresentations or omission of facts in this application may result in my immediate discharge from employment or a revocation of an offer of employment. This application is in no way intended to be a contract. Any employment is contingent upon meeting SBL Fayette County Hospital standards for the placement which includes completion of the post-offer physical examination including urine drug screen, satisfactory results from reference checks, OIG sanction check, and Illinois State Police criminal background check. If you are covered by the Illinois Healthcare Workers’ Background Check Act, you may obtain a copy or the Criminal Conviction Report, challenge its accuracy, and/or request a waiver. It is the policy of SBL Fayette County Hospital to provide opportunities for employment to all qualified applicants according to federal and state law. Applicants are considered without regard to race, religion, gender identity, sexual orientation, age, national origin, veteran or disability.

Enter Signature: *

SBL Fayette County Hospital Job Application

PERSONAL INFORMATION

EDUCATION

EMPLOYMENT INFORMATION

Previous Employment

REFERENCES