Application for Employment

Step 1:

Before you complete the form below, download and fill out this Health Care Worker Background Check

Step 2:

Instructions:

Read every question carefully and answer each question accurately. If a question or item does not apply to you, omit it and if you need to place a note in the comment section. The information requested is to be used to determine your suitability for employment. We are an equal-opportunity employer; we do not discriminate on the basis of sex, religion, age, national origin, color, race, marital status, physical or mental disability, sexual orientation or for any other reason not related to the requirements of the job being applied for.

Personal Data:

First Name (Required):
Last Name (Required):
Middle Name:
Your Email (Required):
Social Security Number (Required):
Do you have a legal right to live and work in the United States?: YesNo
APPLICANT MAY BE SUBJECT TO VERIFICATION OF LEGAL RIGHT TO LIVE AND WORK IN THIS COUNTRY.

List all names you have used:
Home Phone Number:
Cell Phone Number:
Work Phone Number:
May we call you at work?: YesNo

Do You have a Valid Driver's License:YesNo
Driver's License Number:
What job are you applying for? (Required):
Do you have any special skills, which you feel would aid in the job for which you are applying?
Please check the times you are available for work (Required): WeekendsDaysEveningsNightsPRN Hours

Addresses

Starting with your present address, list all addresses where you have lived for the past ten years. (Include dates when you lived there, Address, City, State and Zipcode. (Required)

Employment History:

List your employment history, beginning with your most recent job, including time spent at school and in the military.

Employer 1

Employer #1 (Required):
Supervisor (Required):
Your Title (Required):
Employer's Address (Required):
Employer's Phone (Required):
Starting and Ending Salary:
Dates of employment (Required):
Reason for leaving (Required):

Employer 2

Employer #2:
Supervisor:
Your Title:
Employer's Address:
Employer's Phone:
Starting and Ending Salary:
Dates of employment:
Reason for leaving:

Employer 3

Employer #3:
Supervisor:
Your Title:
Employer's Address:
Employer's Phone:
Starting and Ending Salary:
Dates of employment:
Reason for leaving:

Have you ever been fired from a job? YesNo
Have you ever been employed by Mercy Rehab & Care Center? YesNo
Do you have any relatives employed by Mercy Rehab & Care Center? YesNo

If you answered "Yes" to any of the above questions, please explain, including dates:

Additional Comments:

Upload your completed Healthcare Worker Background Check from Step 1. (Required)