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Moose Lake, Minnesota
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Job Application

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Employment Application

Mission

Mercy Hospital is committed to delivering high quality, personalized care to people of all ages.


Vision

Mercy Hospital is the leading choice of healthcare services within our region, providing exceptional care in collaboration with our partners.



An Equal Employment Opportunity Employer.

We comply with all applicable state and federal civil rights and equal employment laws and regulations.

Mercy Hospital is a smoke free facility.



Personal

Last Name *
First *
Middle
Email


Present Address *
Phone *
City *
State *
ZIP Code *



Position applied for? *
Salary desired? *
How were you referred to this facility?
Are you applying for... *
Full TimePart TimeRegularTemporary
Have you ever been employed by this facility? *
YesNo
(When?)
Are you at least 18 years of age? *
YesNo
Date Available For Work *
Long-range occupational goals: *
Would you consider working... *
Any Shift?Weekends & Holidays?Rotating Shifts?On Call?
Are you a U.S. citizen or an alien legally authorized to work in the United States? *
YesNo



Education/Skills

School
Name and address
Course of study
Last year completed
Did you graduate?
List Diploma or Degree
School
High School *

Name and address *
Course of study
Last year completed *
1234
Did you graduate? *
YesNo
List Diploma or Degree *
School
College 1

Name and address
Course of study
Last year completed
1234
Did you graduate?
YesNo
List Diploma or Degree
School
College 2

Name and address
Course of study
Last year completed
1234
Did you graduate?
YesNo
List Diploma or Degree
OTHER - Business College or Special Courses (include special military training, post-graduate, and nursing)
Area of specialization or major interest
Typing: Approx WPM
List Health Care, Business, or Industrial equipment operated:

Professional Licenses and/or Certifications

Are you currently:
RegisteredLicensedCertified
Are you eligible for:
RegistrationLicensureCertification
If currently licensed, registered, or certified:
Certification Type
State
Date
Number
Certification 1
Type
State
Date
Number
Certification 2
Type
State
Date
Number
Certification 3
Type
State
Date
Number



Previous Experience

List name, address, and phone number of previous employers with most recent employer first.

Job 1
Title
Immediate Supervisor
Worked from...
to...
Last Salary

Hourly, Monthly, or Yearly
Employer Name
Employer Phone
Employer Address
Job Duties
Reason for Leaving


Job 2
Title
Immediate Supervisor
Worked from...
to...
Last Salary

Hourly, Monthly, or Yearly
Employer Name
Employer Phone
Employer Address
Job Duties
Reason for Leaving


Job 3
Title
Immediate Supervisor
Worked from...
to...
Last Salary

Hourly, Monthly, or Yearly
Employer Name
Employer Phone
Employer Address
Job Duties
Reason for Leaving


Job 4
Title
Immediate Supervisor
Worked from...
to...
Last Salary

Hourly, Monthly, or Yearly
Employer Name
Employer Phone
Employer Address
Job Duties
Reason for Leaving


Special Skills and Qualifications

Summarize special skills and qualifications acquired from employment or other experience. *

Did you serve in the U.S. Armed Services? *
YesNo
What Branch?
Have you volunteered your time or services? *
YesNo
Where?
Do you have a relative employed with us? *
YesNo
If yes, please list their name(s) and title(s) below.



References

List at least 3 references who are not relatives or employers:

Reference 1
Name and Relationship
Title
Company Address
Telephone
Reference 2
Name and Relationship
Title
Company Address
Telephone
Reference 3
Name and Relationship
Title
Company Address
Telephone
Reference 4
Name and Relationship
Title
Company Address
Telephone



Signature

Read this section prior to providing signature below

In consideration of my employment, I agree to conform to the rules and regulations of this facility. I understand that my employment can be terminated at any time and for any reason, at the option of either the facility or myself. I understand that no one has any authority to enter into any agreement for employment for any specified period of time or to make any agreement contrary to the foregoing, except for a written employment agreement signed by an administrative representative of this facility.

I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete. I understand that any false or misleading representations or omissions may disqualify me from further consideration for employment and may result in discharge even if discovered at a later date.

I hereby authorize persons, schools, my current employer (if applicable) and previous employers and organizations named in this application (and accompanying resume, if any) to provide this facility and all affiliates with any relevant information regarding an employment decision, and I release all such persons from any liability regarding the provision or use of such information.

Date *
Signature *



Mercy Nepotism Policy

EMPLOYMENT APPLICATION SUPPLEMENT

Nepotism Notification for Applicants

Mercy Hospital has a Nepotism Policy which means: There are some restrictions on the hiring of applicants who are immediate family members related to certain classifications of employees currently employed at Mercy. As a result of the existence of the Nepotism Policy we ask that you make us aware of your relationship to the following list of employees in these positions.

Members of the Board of Directors

Chief Executive Officer

Director of Finance

Director of Human Resources

Director of Patient Care Services

Director of Quality & Health Information

If you are unsure of the names of the employees in these positions, please request a listing of these individuals. If you would like to review the Mercy Nepotism Policy prior to the completion of your application to confirm whether or not Mercy's Nepotism Policy classifies you as an immediate family member a copy will be provided for your review.

We ask that you verify your understanding of the above statement and disclose your relationship to any of the above named individuals.

I acknowledge that I am aware of the existence of Mercy's Nepotism Policy. *
YesNo

To my knowledge I am not an immediate family member related to any of the above named individuals. *

Signature



Mercy Pre-Employment Drug Testing Policy

NOTICE OF ADOPTION OF PRE-EMPLOYMENT DRUG TESTING POLICY

Effective October 1, 2009, Mercy Hospital has adopted a Drug Testing Policy for all job applicants who receive a conditional offer of employment. Failing a drug test may result in revocation of the job offer.

Drug testing will be conducted on all job applicants who have been made conditional offers of employment.

All testing for drugs will be conducted by a legally authorized laboratory. Precautions will be taken to maintain the confidentiality of test results.

Applicants who refuse to test, or test positive or dilute on a confirmatory test, will have their offers of employment revoked.

Copies of the Mercy Hospital Controlled Substances and Alcohol Policy will be issued to all applicants who have been made conditional offers of employment.



Minnesota Applicant Data Record

EMPLOYMENT APPLICATION SUPPLEMENT

Applicants are considered for all positions, and employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital status or veteran status, medical condition or handicap, or any other legally protected status. As employers/governmental contracts, we comply with government regulations, including affirmative action responsibilities where they apply.

Solely to help us comply with government record keeping, reporting, and other legal requirements, we request that you please fill out the Applicant Data Record. We appreciate your cooperation.

This data is for periodic government reporting and will be kept in a confidential file separate from the Application for Employment.

YOUR COOPERATION IS VOLUNTARY

Position applied for
Date
Referral Source:
AdvertisementFriendRelativeWalk-inMercy EmployeePosted Job AnnouncementEmployment AgencyOther
Applicant's Name:

Affirmative Action Survey:
Government agencies require periodic reports on the sex, ethnicity, handicapped, and veteran status of applicants. This data is for analysis and affirmative action only.

Check one:
MaleFemale
Check one of the following:
WhiteBlack or African AmericanAmerican Indian/Alaskan NativeAsianPacific IslanderHispanic or LatinoTwo or more races
Check if you wish to identify yourself as the following:
Vietnam Era VeteranDisabled VeteranHandicapped Person
If so, do you require any special accommodations to participate in the application process for this position?
YesNo