Board Certified Physicians

Employment Application

An Equal Opportunity Employer.  We comply with all applicable local, state and federal civil rights and equal employment laws and regulations.

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.

Personal

LAST NAME
 FIRST
 MIDDLE
  
PRESENT ADDRESS
 CITY
 STATE
 ZIP CODE
PERMANENT ADDRESS
 CITY
 		 STATE
 ZIP CODE
HOME TELEPHONE NO.
 CONTACT TELEPHONE NO.
 E-MAIL ADDRESS
 BEST TIME TO CONTACT YOU:
DATE AVAILABLE FOR WORK:
 ARE YOU APPLYING FOR
FULL TIME PART TIME
REGULAR TEMPORARY
POSITION APPLIED FOR:
 SALARY DESIRED:
WOULD YOU CONSIDER WORKING:
WEEKENDS & HOLIDAYS
YES       NO		 ROTATING SHIFTS
YES       NO		 ON CALL
YES       NO		 ANY SHIFT
YES       NO
HOW WERE YOU REFERRED TO THIS FACILITY?
RELATIVES OR FRIENDS EMPLOYED IN THIS FACILITY? NAME:
 DEPT:
 RELATIONSHIP:
HAVE YOU EVER BEEN EMPLOYED BY THIS FACILITY?
YES

WHEN:
NO
ARE YOU 18 YRS OF AGE OR OLDER?
YES     NO 		ARE YOU A U.S. CITIZEN OR AN ALIEN LEGALLY AUTHORIZED TO WORK IN THE UNITED STATES?
YES     NO
LONG RANGE OCCUPATIONAL GOALS:
 SHIFT PREFERENCE:
DAYS          
EVENINGS    
NIGHTS       

HAVE YOU EVER BEEN CONVICTED OF, OR PLEAD GUILTY TO, A CRIME OTHER THAN MISDEMEANOR TRAFFIC VIOLATIONS?
 YES     NO
IF YES, WHICH STATE(S), AND EXPLAIN:  (You are not required to disclose any SEALED or EXPUNGED criminal records.)

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?   YES     NO    IF YES, WHICH STATE(S), AND EXPLAIN:

HAVE YOU EVER BEEN SANCTIONED, CITED, REPORTED, OR EXCLUDED FROM PARTICIPATION IN MEDICARE, MEDICAID, OR ANY OTHER HEATHCARE RELATED LAW OR REGULATION?  YES     NO    IF YES, EXPLAIN:

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

Under Illinois state law, we have an obligation to inform you that it is a civil rights violation for any Illinois employer to inquire about or to use arrest information or criminal history record information that has been ordered expunged, sealed or impounded.

Therefore, you do not have to answer YES when asked on this application if you have been convicted of or plead guilty to, a crime other than misdemeanor traffic violations IF AND ONLY IF you record has been sealed or expunged.