Employment Application

Basic Info

Name *

Home phone number

Present address *

How long have you lived there?

Permanent address

Are you 18 years of age or older? *

In case of emergency notify

Relationship

Address

Phone # *

Employment / Personal Data

Position desired

Experience?

Pay expected $

Date available

Month

Day

Year

On call

Shift desired

1st

2nd

3rd

Rotating

Willing to work

Full Time

Part Time

Weekends

Have you filled out an application here before?

Date

Month

Day

Year

Have you ever been employed here before?

Date

Month

Day

Year

Are you a citizen of the United States?

Do you have any friends, relatives, other than your spouse working here?

If yes, please list name(s) and relationship

Are you on lay-off and subject to recall?

Have you ever been subject of investigation, suspended or otherwise restricted from participating in any private, federal, or state health insurance program?

Do you have any physical conditions which may require an accommodation to perform the particular job for which you are applying?

Education Data

Highest level of education completed

High School

Name of School

Location

Grad?

Course

College

Name of School

Location

Grad?

Course

Additional College

Name of School

Location

Grad?

Course

Graduate

Name of School

Location

Grad?

Course

Technical or Professional

Name of School

Location

Grad?

Course

Other

Name of School

Location

Grad?

Course

Degree

Major field

Are you studying now?

What?

Personal References ( not employer or relative )

Primary reference

Name / Occupation

Address

Phone

Business

Additional reference

Name / Occupation

Address

Phone

Business

Additional reference

Name / Occupation

Address

Phone

Business

Contact us at jobs@mercer-health.com
Fax: 419.678.5674
Mail: attn: Human Resources
Mercer Health
800 West Main St.
Coldwater, OH 45828