Morrison Community Hospital

Morrison Community Hospital 303 North Jackson Street Morrison, IL 61270 | Main: 815-772-4003 | Clinic: 815-772-5511

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Please fill out the online application to the best of your ability and be sure and be sure to fill in the fields that are marked with a red * as those are required fields.

Contact Information

Position Applying For*:

Date Available To Start*:

Full Name*:

Street Address*:

City*:

State*:

Zip*:

Phone*:

Email*:

Personal Information

Salary Desired:

How were you referred to this facility?*:

Do you have relatives/friends employed at this facility? If yes, please list name, department and relationship:

Have you ever been employed by this facility?*:

YesNo

If previously employed please tell us when:

Are you 18 years of age or older?*:

YesNo

Are you a U.S. citizen or an alien legally authorized to work in the United States?*:

YesNo

Long range occupational goals:

Criminal Record

If your answer is "yes" to any of the following 3 questions, you will not be automatically disqualified from employment consideration, except as required by state or federal law.

Have you ever been convicted of, or plead guilty to, a crime other than misdemeanor traffic violations? If yes, which states and explain*:

Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this or any other state of the United States? If yes, which states and explain.*:

Have you been sanctioned, cited, reported, or excluded from participation in medicare, medicaid, or any other healthcare related law or regulation? If yes, explain.*:

Job Position Considerations

Are you applying for*:

Full TimePart TimeRegularTemporary

Regarding working hours, please check all that you would be willing to work*:

Weekends & HolidaysRotating ShiftsOn CallAll Shifts

Shift Preference*:

DaysEveningsNights

Best time to contact you*:

High School Education

School Name*:

Dates Attended*:

Degree Earned*:

College and Additional Education

Please list all colleges along with dates and degrees earned in the space provided*:

Please list other business colleges, special courses (include special military training, post graduate and nursing):

Please list additional areas of specialization as well as health care, business or industrial equipment operated, office skills and computer/software experience:

Professional Licenses

Professional License Information:

Currently LicensedEligible for LicenseCurrently RegisteredEligible for Registration

License type, no., state and date (if applicable):

License or registration ever suspended, revoked or on probation?:

YesNo

If yes, please explain:

Professional Certifications:

Currently CertifiedEligible for Certification

If Certified, please list type, state and date:

Previous Work Experience

Please use the following fields to provide information regarding previous employment beginning with the most recent employer. Please use this space to list your

employer
job title
job responsibilities
date started/ended
reason for leaving
and your supervisor's name

Job 1 (most recent)*:

Job 2*:

Job 3*:

May we contact your current employer?*:

YesNo

References

Please list the names and phone numbers of at least 3 references*:

General Information

Applicants with direct patient care: Please describe your personal philosophy about patient care:

What is your biggest strength(s)? How would your strength(s) enhance your service at Morrison Community Hospital?:

Why would you like to work at Morrison Community Hospital?*:

Authorization

In considering your application for employment, the facility may conduct a detailed and thorough investigation which may include but is not limited to a criminal record check, interviews or inquiries of prior employers, coworkers, acquaintances, relatives or friends.

Authorization*:

Yes I understand by checking this box and submitting my application to Morrison Community Hospital, I am giving them permission to carry out these investigations

Verification:

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