Secure Application for Employment
HR7940 Rev 07/02
Human Resources Department
650 West Taylor
Vandalia, Illinois 62471
Phone: (618) 283-5551
Heartland Health System, Inc. is an equal opportunity employer and does not discriminate against
applicants or employees in any phase of employment on the basis of age, race, color, gender,   
religion, national origin, ancestry, physical or mental disability, or any other classification     
protected by local, state, or federal law. Equal access to employment, services, and programs 
is available to all qualified persons. Applicants requiring reasonable accommodation for the  
application and/or interview process should notify a Company representative.                        
http://www.fayettecountyhospital.org
email:  human.resources@fayettecountyhospital.org
Date
This application is valid for 60 days. If you wish to be considered for employment after this 60-day period, a new application must be completed.
Last Name                                    First Name                                  Middle Initial
   
Are You Younger Than 18 Years Of Age?

If you are under 18,
please indicate age and date of birth:

Home Phone And Cell Phone

Present Address

Present City

Present State

Present Zip Code

E-Mail Address

Permanent Address (if different)

Permanent City

Permanent State

Permanent Zip

Current Open Position(s) for Which You Are Applying



Type of Position
Per Diem
Full Time
Part Time
Temporary
Shift

Day
Night
Evening
Rotation
Salary Requirement
$
Are you available to work holidays and weekends?
Indicate the date and times of your availability:
Date Available For Work

Are You Legally Authorized to Work in the U.S.?
Have you ever worked in this facility?
If yes, what facility? If yes, please list the date(s) of employment, Position held, Supervisor(s) names, and under what name(s) you worked. Are you related to anyone employed at Fayette County Hospital and Long Term Care or Heartland Health System, Inc?
If yes, Please provide the Name, Department, and Facility worked at:
How did you learn about this position?
State Employment
         Commission

Internet
Agency
Ad
Job Listing
School
Current Employee
Job Line
Other:

Are you able to perform the essential, job related functions of the position for which you are applying with or without reasonable accommodations?
Describe any accommodations necessary:

Have you been convicted of a crime and/or released from confinement following a conviction for any criminal offense?
Arrests or charges that have been expunged need not be disclosed.
If yes, give date, place and nature of each such conviction.

Are you presently charged with any violation of the law?
If yes, give date, place and nature of each such event:

Are you currently excluded from participation in any federally funded healthcare program - including Medicare and Medicaid - and are you
aware of any potential exclusion from a federally funded health program?
Educational History
Type of School
Name of School

City, State
Check Last Year
Attended in School

Degree or Certificate
High School
School:
    City:
   State:
9   10   11   12
Graduated/GED?
Degree:
College
School:
    City:
   State:
1     2     3    4
Graduated?
Degree:
College
School:
    City:
   State:
1    2    3     4
Graduated?
Degree:
Graduate
School

School:
    City:
   State:
1    2     3    4
Graduated?
Degree:
Other
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:
Other
School:
    City:
   State:
1    2    3    4
Graduated?
Degree:
List any professional licenses, registration or certification you possess
(Include only the last 4 digits of your Driver's License, if applicable)
Include Type, State Issued, Expiration Date and Number.
Indicate if any licenses have been revoked, suspended or placed on probation.
Also indicate if you are ineligible to become licensed or certified in your field. Please explain.

Clerical or other skills applicable to the position for which you are applying
Typing (WPM)              PBX
Proficient in Software: 
Business machines and/or equipment you can operate:
      
Other