Massac Memorial Hospital

If you are interested in a career opportunity with our company, please enter your contact information. Thank you for your interest in Massac Memorial Hospital! (fields marked with an * are required.)
First Name:*
Middle Initial:
Last Name:*
Home Phone:*	Preferred Phone Number
Work Phone:	Preferred Phone Number
Cell/Mobile Phone:	Preferred Phone Number
Pager Number:	Preferred Phone Number
Email: *
Address: *

City/Town: *
State: *
Zip/Postal Code: *
County: *
Country:

Alternate Address:

City/Town:
State:
Zip/Postal Code:
County:
Country:

POSITION INFORMATION (if hired)
Name of position (type of position) which you are applying for? *
Indicate type of position for which you are applying: *
Would you consider working: Weekends Yes No Holidays Yes No On Call Yes No
List all relatives or friends employed at MMH and relationship to you:
Are you a U.S. citizen, or an alien legally authorized to work in the United States? * Yes No
Are you 18 years of age or older: Yes No
Please Specify your Shift Preference: * Select all that apply. To select multiple, press Ctrl key with mouse click.

EDUCATION
High School:
Last Year Completed:	1 2 3 4
Did you graduate?	Yes No
College:
Course of Study:
Last Year Completed:	1 2 3 4 6 8
Did you graduate?	Yes No
Degree earned:	Certificate Associates Bachelors Masters PhD
Other College Or Trade School:
Course of Study:
Last Year Completed:	1 2 3 4 6 8
Did you graduate?	Yes No
Degree earned:	Certificate Associates Bachelors Masters PhD
Other specialized education/training:
List office skills including computer/software experience:
Word Processing Speed:	WPM
List Healthcare, Office, Maintenance, Other equipment with which you have successfully operated:

LICENSING AND REGISTRATION
Professional License/Certification:	Currently Licensed in the state of Illinois Currently Registered in the state of Illinois Eligible for License Eligible for Registration None
What type of license/certification do you have/are you eligible for?
Has this License or Registration EVER been suspended, revoked or on probation? Yes No
Explain:

EMPLOYMENT HISTORY
Have you ever been employed by Massac Memorial Hospital? Yes No
If yes, when?

Current or most recent employment:
Job Title:
Employer:
From: (please use MM/DD/YYYY format)	To:
Salary:	(list Hr/Mo/Yr)
Supervisor:
Supervisor's Phone Number:
Duties:
Reason for Leaving:

Previous Employment:
Job Title:
Employer:
From: (please use MM/DD/YYYY format)	To:
Salary:	(list Hr/Mo/Yr)
Supervisor:
Supervisor's Phone Number:
Duties:
Reason for Leaving:

Previous Employment:
Job Title:
Employer:
From: (please use MM/DD/YYYY format)	To:
Salary:	(list Hr/Mo/Yr)
Supervisor:
Supervisor's Phone Number:
Duties:
Reason for Leaving:

Previous Employment:
Job Title:
Employer:
From: (please use MM/DD/YYYY format)	To:
Salary:	(list Hr/Mo/Yr)
Supervisor:
Supervisor's Phone Number:
Duties:
Reason for Leaving:

May we contact the employers listed above? Yes No
If not, please indicate below which ones you do not wish us to contact.
List all previous name(s) under which you worked including maiden name(s):

CRIMINAL HISTORY
Note: You are not required to disclose any sealed or expunged criminal records. Conviction means you were found guilty by a judge, a jury, by pleading "no contest," or by pleading guilty in court. A conviction may have taken place even if you did not pay a fine or spend any time in jail or prison. A conviction will not automatically disqualify you from employment.
Have you ever been involved in the substantiated abuse or neglect of children or adults? Yes No
Have you ever been sanctioned, cited, reported, or excluded from participation in Medicare, Medicaid, or any other healthcare related law or regulation? Yes No
If yes, explain:
Have you ever been convicted of a felony or a misdemeanor (including, but not limited to such offenses as DUI, battery, theft, writing worthless checks, etc.)? * Yes No
If yes, what charges and dates?
Have you ever pled nolo contendere or pled guilty to a crime, which is a felony or a misdemeanor (including, but not limited to such offenses as DUI, battery, theft, writing worthless checks, etc.)? * Yes No
If yes, what charges and dates?
Have you ever had the adjudication of guilt withheld to a crime, which is a felony or a misdemeanor (including, but not limited to such offenses as DUI, battery, theft, writing worthless checks, etc.)? * Yes No
If yes, what charges and dates?

Agree * I have completed all appropriate fields on the above application, and have read the following paragraphs: I certify that all of the information I have given in this document is accurate and complete and is subject to verification by the Massac Memorial Hospital. In addition, my previous and present employers may be asked for information relative to my employment record with them. 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 any omission or misrepresentation of material facts in this document may result in disqualification and/or disciplinary action up to and including termination of employment even if discovered at a later date. Further, in cases where job specifications state that I must meet certain educational requirements, I must be able to submit to the Human Resources Department: a high school diploma, general educational development (GED) certificate, a transcript of my college credits and/or copy of my degree, diploma or certification, as appropriate. Please Note: This online application is not an offer for a contract of employment.