APPLICATION FOR EMPLOYMENT

An Equal Opportunity Employer

Applications are kept on file for a minimum of one year. You may update your application upon request. Applications will be considered at the time of receipt. If you wish to update your application or request additional consideration, you must contact the HR department.

Please Print in Ink

NAME: Click here to enter text. DATE: Click here to enter text.

Last, First Middle

CURRENT ADDRESS: Click here to enter text.

Street, City, State Zip

PREVIOUS ADDRESS: Click here to enter text.

Street, City, State Zip

HOME/CELL PHONE: Click here to enter text. WORK PHONE: Click here to enter text.

EMPLOYMENT DESIRED

Position: Click here to enter text. Date you can start: Click here to enter text.
☐ Full time ☐ Part time ☐ Temporary Hours available: Click here to enter text.
Have you ever been employed by the BENEDICTINE HEALTH SYSTEM (BHS) or a BHS affiliate? ☐ Yes ☐ No
If yes, please complete the following: Dates Employed: Click here to enter text.
Position Held: Click here to enter text. Immediate Supervisor: Click here to enter text.
Facility/Location: Click here to enter text. Reason for Leaving: Click here to enter text.
Do you currently have any relatives employed with BHS? ☐ Yes ☐ No If so, who: Click here to enter text.
REFERRED BY
☐ Current Staff Member (Employee’s Name): Click here to enter text. ☐ State Job Service
☐ Ad (Name of Publication): Click here to enter text. ☐ None - Walk-in
☐ Other: Click here to enter text.

BHS does not illegally discriminate on account of an applicant's age. If you are under 18, you may be required to prove your age for some jobs where state laws or regulations impose restrictions.

Are you 18 years of age or older? ☐ Yes ☐ No

SCHEDULING

Every nursing facility must be staffed 7 days a week, 24 hours a day. Work schedules are varied and require flexibility. Based on our staffing needs, we may not always be able to accommodate your scheduling preferences. Therefore, please consider carefully all of your personal time commitments before responding to the following questions:
Check shift preference: ☐ Day ☐ Evening ☐ Night ☐ No preference, I can work any shift
2nd Choice: ☐ Day ☐ Evening ☐ Night Can you rotate shifts: ☐ Yes ☐ No

WORK EXPERIENCE

Indicate all work experience beginning with your current or most recent position. Complete all sections.

Date (Month/Year) / Name & Address of Employer:
Click here to enter text. / Position:
Click here to enter text. / May we contact for reference?
☐ Yes ☐ No
From:
Click here to enter text. / Supervisor:
Click here to enter text. / Phone No.
Click here to enter text.
To:
Click here to enter text. / Final Salary:
Click here to enter text.
Duties:
Click here to enter text.
Reason for Leaving:
Click here to enter text.
Date (Month/Year) / Name & Address of Employer:
Click here to enter text. / Position:
Click here to enter text. / May we contact for reference?
☐ Yes ☐ No
From:
Click here to enter text. / Supervisor:
Click here to enter text. / Phone No.
Click here to enter text.
To:
Click here to enter text. / Final Salary:
Click here to enter text.
Duties:
Click here to enter text.
Reason for Leaving:
Click here to enter text.
Date (Month/Year) / Name & Address of Employer:
Click here to enter text. / Position:
Click here to enter text. / May we contact for reference?
☐ Yes ☐ No
From:
Click here to enter text. / Supervisor:
Click here to enter text. / Phone No.
Click here to enter text.
To:
Click here to enter text. / Final Salary:
Click here to enter text.
Duties:
Click here to enter text.
Reason for Leaving:
Click here to enter text.
Date (Month/Year) / Name & Address of Employer:
Click here to enter text. / Position:
Click here to enter text. / May we contact for reference?
☐ Yes ☐ No
From:
Click here to enter text. / Supervisor:
Click here to enter text. / Phone No.
Click here to enter text.
To:
Click here to enter text. / Final Salary:
Click here to enter text.
Duties:
Click here to enter text.
Reason for Leaving:
Click here to enter text.

EDUCATION

School / Name and Location / Did you
Graduate? / Certificate Received / Degree Received / Subject Studied
High School / Click here to enter text. / ☐Yes
☐No / Click here to enter text. / Click here to enter text. / Click here to enter text.
College / Click here to enter text. / ☐Yes
☐No / Click here to enter text. / Click here to enter text. / Click here to enter text.
Trade School / Click here to enter text. / ☐Yes
☐No / Click here to enter text. / Click here to enter text. / Click here to enter text.
Other (seminars, military schools, etc.) / Click here to enter text. / ☐Yes
☐No / Click here to enter text. / Click here to enter text. / Click here to enter text.

LICENSE/CERTIFICATION Complete this section if a license/certification is required to perform the duties of the job for which you are applying.

Type License/Certification / State / Number / Expiration Date / (Facility Use Only)
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
If you don't have the required license for this job, have you applied? ☐ Yes ☐ No
If an exam is required to obtain the required license, give scheduled date Click here to enter text.
If not licensed in this state, have you applied for reciprocity? ☐ Yes ☐ No

SKILLS List any additional skills you have that add to your qualification for this position (for example, EMT or CPR training).

Click here to enter text.

PERSONAL REFERENCES List any other references other than relatives or former employers that we may contact.

Name and Telephone / Address / Occupation / Years Acquainted
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
Click here to enter text. / Click here to enter text. / Click here to enter text. / Click here to enter text.
The Benedictine Health System is an Equal Opportunity Employer.
This statement is to affirm the Benedictine Health System’s policy for providing equal opportunities to all employees and applicants for employment in accordance with all applicable equal employment opportunity laws, directives and regulations of federal, state, and local governing bodies or agencies thereof.
The Benedictine Health System will not discriminate against any employee or applicant for employment because of race, religion, national origin, sex, disability, age, or membership in any other protected class.
The Benedictine Health System will work to ensure that all employment practices are free of discrimination.

PROFESSIONAL RECORD

Have you ever had a finding entered into the State Nurse Aide Registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property? ☐ Yes ☐ No
If “Yes”, explain: Click here to enter text.
Have you ever been or are you in the process of being excluded from participation in any state or federal health care programs?
☐ Yes ☐ No
If “Yes”, explain: Click here to enter text.
By signing below, I am certifying that all information provided by me in this application is true and complete to the best of my knowledge. I understand that, if employed, falsified statements on this application shall be grounds for dismissal, whenever discovered.
I authorize investigation of the truth and completeness of all information provided by me in this application. In consideration of providing information to assist me in my employment search, I hereby release any and all sources of such information, along with their agents and employees, from any claims I may have arising out of the disclosure of information about me.
In consideration of the Employer considering me for employment, I hereby release the Employer, along with its agents and employees, from any and all claims I may have arising from the Employer seeking information about me in connection with my application for employment with the Employer.
By signing below, I am agreeing that if I am hired, unless otherwise provided in a signed written agreement, my employment may be terminated by me or by the Employer at any time, for any reason, and with or without cause. I agree that neither this application nor any personnel manual which I may receive upon employment is intended to be a contract of employment.
I agree that any offer of employment is conditioned on (i) verification of my right to work in the United States; (ii) passing a Tuberculosis test (if applicable to the position); (iii) satisfactory completion of a criminal background investigation, and if applicable, a driving record investigation; and (iv) receipt of favorable references (as determined in the sole discretion of the Employer). I agree that any offer of employment may also be conditioned on (i) demonstration of physical and mental ability to perform essential job functions (when a physical exam or testing is required for the job position, all applicants will be given the same testing); (ii) passing a literacy examination; and (iii) verification of any required license or registration and confirmation that no discipline, investigation, or conditions will affect my ability to work under that license or the license of another, as determined in the Employer’s sole discretion.
I acknowledge receiving a copy of the Employer’s Affirmative Action Policy Statement and a copy of the job description for which I am applying.
Click here to enter text. Click here to enter text.
Applicant (Signature Required at time of interview, if granted) Date

Thank you for completing this application and for your interest in our organization.

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