Mercer Health Employment Application

Step 1 of 2

Basic Info

Name(Required)

Phone Number(Required)

Home Address(Required)

Email(Required)

Are you 18 years of age or older?(Required)

Emergency Contact Name(Required)

Emergency Contact Phone Number(Required)

Relationship

Career Interest

Job Position Desired(Required)

Pay expected(Required)

Date available(Required)

Willing to work(Required)

Full Time

Part Time

Weekends

Casual

Summer Only

Shift desired(Required)

1st

2nd

3rd

Rotating

Have you filled out an application here before?(Required)

Date

Have you ever been employed here before?(Required)

Date

Are you a citizen of the United States?(Required)

Please list name(s) and relationship of any relatives or friends that work at Mercer Health:

Education

Name of School 1(Required)

Location(Required)

Date Began

Date Graduated ("No" if not completed)(Required)

Degree or Course of Study(Required)

Name of School 2

Location

Date Began

Date Graduated ("No" if not completed)

Degree or Course of Study

Name of School 3

Location

Date Began

Date Graduated ("No" if not completed)

Degree or Course of Study

Professional Licenses/Certifications

License/Certification 1

Organization or State Issued

Date Issued

License Number

Expiration Date

License/Certification 2

Organization or State Issued

Date Issued

License Number

Expiration Date

License/Certification 3

Organization or State Issued

Date Issued

License Number

Expiration Date

Special Skills and Abilities

List any electronic records systems or office machines you can operate skillfully(Required)

Write here any additional information which you feel might affect your application

Upload Your Resume / Cover Letter

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 300 MB, Max. files: 3.

Work History (Record U.S. Military Services as a position)

Past Employer #1 Name(Required)

Employer #1 Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer #1 Phone Number(Required)

Employment From(Required)

Employment To(Required)

Job Title(Required)

Starting Pay Rate(Required)

Final Pay Rate(Required)

Reason for Leaving(Required)

Name of Immediate Supervisor(Required)

Past Employer #2 Name(Required)

Employer #2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer #2 Phone Number

Employment From

Employment To

Job Title

Starting Pay Rate

Final Pay Rate

Reason for Leaving

Name of Immediate Supervisor

Past Employer #3 Name

Employer #3 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer #3 Phone Number

Employment From

Employment To

Job Title

Starting Pay Rate

Final Pay Rate

Reason for Leaving

Name of Immediate Supervisor

Indicate by number (1 - 3) any of the above employers whom you do not wish us to contact and please explain why.

Personal References (Not a Relative)

Reference #1 Name & Occupation(Required)

Business(Required)

Phone Number(Required)

Reference #2 Name & Occupation(Required)

Business(Required)

Phone Number(Required)

Reference #3 Name & Occupation(Required)

Business(Required)

Phone Number(Required)

Application Specifications

I certify that the answers given by me to the forgoing questions and statements are true and correct. I agree that Mercer Health shall not be liable in any respect if my employment is terminated because of falsification of statements, answers, or omissions made by me in this questionnaire. I expressly authorize Mercer Health to check my employment references to determine my suitability for employment. I also authorize the companies, schools, or persons named to give any information regarding my employment, character, and qualifications. I hereby release said companies, schools or persons from liability for any damages for issuing this information.

I understand that if I am employed, it would be for an introductory period; that if, in the judgement of the institution, I prove unsatisfactory during this period, the employment may be terminated by the hospital without notice; and that after this introductory period, the employment may be terminated by either party upon notice to the other. I also understand that my employment at Mercer Health is contingent upon the satisfactory recommendations from former employers and references.

Signature of applicant(Required)

Today's Date(Required)

CAPTCHA

Top