Mercy Chicago :: Living Well in the City

EMPLOYMENT APPLICATION
Mercy Hospital & Medical Center does not discriminate in hiring or employment on the basis of race, color, religion, national origin, sex, sexual orientation, age, ancestry, marital status, veteran status or any other status protected by applicable federal, state or local law.
Date:

I am interested in the following position(s):


I am available to work (Check all that apply): Full-Time Part-Time Temporary Registry Days Evenings Nights Weekends Note: Work schedules are based on the operational needs of the department.
PERSONAL INFORMATION
Last Name:
Middle Name:
First Name:
Address:
City:
State:
Zip Code:
Phone Number (Home):
Phone Number (Work):
If you have no phone, how may we contact you?
Are you at least 18 years of age? Yes No (If no, you will be required to provide authorization to work.)
Are you legally eligible to be employed in the United States? (Proof of identity and eligibility will be required upon employment.) Yes No
Date Available For Work:
How were you referred to Mercy? Newspaper/Magazine Internet Walk-In Job Line Current Previous/Employee Name: Other
Are any of your relatives presently employed by Mercy Hospital & Medical Center? Yes No
If yes, provide name and relationship:
Have you ever been employed by Mercy Hospital and Medical Center? Yes No
If yes, provide dates of employment and position(s):
Have you ever been convicted of a crime, including a misdemeanor? Yes No Please be advised that you are not required to disclose any arrest which did not lead to a conviction. In addition, you are not required to disclose sealed or expunged records of conviction.
If yes, please list the date and types of conviction for each instance: (Convictions will not automatically disqualify job candidates. The seriousness of the crime and date of conviction will be considered.)
If applicable, do you have a current Health Care Worker Waiver from the Illinois Department of Public Health? Yes No
In order to verify educational records and references, please list any other names you have used:
EDUCATION

High School
School Name/Address (include city and state)
Number of Years Attended
Course of study
Diploma/Degree Earned
College
School Name/Address (include city and state)
Number of Years Attended
Course of study
Diploma/Degree Earned
College:
School Name/Address (include city and state)
Number of Years Attended
Course of study
Diploma/Degree Earned
Graduate
School Name/Address (include city and state)
Number of Years Attended
Course of study
Diploma/Degree Earned
Professional
School Name/Address (include city and state)
Number of Years Attended
Course of study
Diploma/Degree Earned
ADDITIONAL SKILLS AND QUALIFICATIONS List any additional skills, experience or other qualifications which you would like to have considered in your application for employment (include vocational training, military experience and/or continuing clinical/technical speciality training):

REGISTRATION/LICENSURE/ CERTIFICATION (Please check all that apply.)
Registration
Type
State Issued/Exp. Date
Number
License
Type
State Issued/Exp. Date
Number
License
Type
State Issued/Exp. Date
Number
Certification
Type
State Issued/Exp. Date
Number
Certification
Type
State Issued/Exp. Date
Number

EMPLOYMENT HISTORY Begin with your most recent employment and continue in reverse order with all your past employment. (Attach an additional sheet if necessary.) We will assume that we have your permission to contact these employers unless you indicate otherwise. Please attach a resume if available.
Position:
Employer:
Employer Address:
Phone Number:
Job Duties:
Reason For Leaving
Supervisor Name:
Supervisor Title:
Salary
Start Date/End Date:

Position:
Employer:
Employer Address:
Phone Number:
Job Duties:
Reason For Leaving
Supervisor Name:
Supervisor Title:
Salary
Start Date/End Date:

Position:
Employer:
Employer Address:
Phone Number:
Job Duties:
Reason For Leaving
Supervisor Name:
Supervisor Title:
Salary
Start Date/End Date:

Position:
Employer:
Employer Address:
Phone Number:
Job Duties:
Reason For Leaving
Supervisor Name:
Supervisor Title:
Salary
Start Date/End Date:

Position:
Employer:
Employer Address:
Phone Number:
Job Duties:
Reason For Leaving
Supervisor Name:
Supervisor Title:
Salary
Start Date/End Date:

Have you ever been discharged by an employer or asked to resign? Yes No
If yes, please explain:
Please explain any periods during which you experienced a break in employment:
Please paste your cover letter into the following box:

Please paste your resume into the following box:


Mercy Values Assessment
C.A.R.E.S. Compassion Accountability Respect Excellence Service We are committed to responding to the needs of those we serve with kindness and empathy. We are responsible for conserving and developing Mercy‘s human, material and financial resources. We believe in treating everyone with the dignity and respect due them as human beings, affirming the principles of honesty, integrity, openness and good faith. We call one another to be the best that we can be. We strive to create a healing environment of hospitality and quality care.
Which value most accurately describes you? Why?

Give a recent example, in your previous experience, of how a set of values helped you to deliver high quality service.


PROFESSIONAL REFERENCES

Name:
Professional Relationship:
Company
Current Phone Number (include area code)

Name:
Professional Relationship:
Company
Current Phone Number (include area code)

Name:
Professional Relationship:
Company
Current Phone Number (include area code)

NOTICE TO ALL APPLICANTS Proof of citizenship or authorization for employment in the United States is required in accordance with the law.

I certify that the information provided in this Employment Application (and any other accompanying or required documents) is true and correct to the best of my knowledge. I understand that any misrepresentation, omission or falsification of information contained in these documents will be cause for the denial of employment or immediate termination of employment, regardless of when or how discovered, and will constitute grounds for immediate dismissal from any subsequent employment at Mercy Hospital and Medical Center. I understand that this application does not constitute an employment contract or an offer of employment. If hired, I agree to conform to the rules and regulations of Mercy Hospital and Medical Center and understand that if employed, my employment is at will and can be terminated at any time, with or without cause and with or without notice, at the option of either Mercy Hospital and Medical Center or myself. In further consideration of my employment at Mercy Hospital and Medical Center, I understand and agree to submit to a reference and criminal background check and understand that my future employment is contingent upon receiving satisfactory results. I further understand and agree that if I am offered employment, it will be contingent upon meeting the physical requirements of the position for which I am applying. I hereby authorize persons, schools, my current employer (if applicable) and/or previous employers named in this application (and accompanying resume) to provide Mercy Hospital and Medical Center with any relevant information used in making an employment decision, and I release all individuals, partnerships, associations and/or corporations from any liability regarding the use of such information. I certify that I have read and understand the foregoing paragraphs.
Electronic Signature Date: