Downloadable Application

Required fields

Your Information

Last Name:* First Name:* Middle Initial:
Present Address:* City:* State:* Zip:*
Present Phone:* Email:*
Permanent Address:* City:* State:* Zip:*
Permanent Phone:*
Best time of day to reach you by phone. At Home: At Work:
Previous Names Used:

Emergency Information

Name:* Address:* Phone:*

Position Information

Position Applying For:* Salary Desired:*
Hours Applying For:*
Date Available:*
Would you consider working... Shift Availability:
Any Shift?
Weekends & Holidays?
Rotating Shifts?
On Call?

How were you referred to Beloit Health System?
Are relatives or friends employed at Beloit Health System?
Department?
Have you ever been employed by Beloit Health System?
If yes, from: ...to...
Are you 17 years or younger?
Long Range Occupational Goals:
Are you a US citizen or are you an alien legally authorized to work in the United States?*
Were you ever convicted of a crime or are there any criminal charges pending against you?*
If yes, describe in full, including date(s):
Have you ever been fired?*
If yes, describe in full, including date(s):

Education / Skills

High School

Name:
Address:
Course of Study:
Years Completed: Did you graduate?
Graduation Year
Last Diploma or Degree:

College

Name:
Address:
Course of Study:
Years Completed: Did you graduate?
Graduation Year
Last Diploma or Degree:

Secondary College

Name:
Address:
Course of Study:
Years Completed: Did you graduate?
Graduation Year
Last Diploma or Degree:

Additional Education

Typing - Approximate Words Per Minute:

Special Courses or Training:

Area of Specialization or Major Interest:

Other Skills:

List health care, business, or industrial equipment operated:

Professional Licenses and/or Certifications

Are you currently:
Eligible for:

If licensed, registered or certified:
Type: State Issued: Date: Number:
Type: State Issued: Date: Number:
Type: State Issued: Date: Number:

Work Experience

List name, address and phone number of previous employers with current employer first.

Current / Previous Job 1

Employer:
Job Title:
Supervisor:
Address:
Phone:
Date - From: ...to...
Duties:
Reason For Leaving:
Last salary: hourly, monthly, or yearly:
May we contact this employer?

Current / Previous Job 2

Employer:
Job Title:
Supervisor:
Address:
Phone:
Date - From: ...to...
Duties:
Reason For Leaving:
Last salary: hourly, monthly, or yearly:
May we contact this employer?

Current / Previous Job 3

Employer:
Job Title:
Supervisor:
Address:
Phone:
Date - From: ...to...
Duties:
Reason For Leaving:
Last salary: hourly, monthly, or yearly:
May we contact this employer?

References

Name: Phone: Relationship:
Name: Phone: Relationship:
Name: Phone: Relationship:

US Military and Volunteer Service

Did you serve in the US Armed Services?
What branch?
Have you volunteered your time or services?
Where?

Remarks

Why are you particularly suited for this job?:

Please read the following very carefully before submitting:

Beloit Health System is an Equal Opportunity Employer and does not unlawfully discriminate in the recruitment or employment of its employees in the basis of race, color, ancestry, national origin, creed, sex, marital status, age, sexual orientation, physical or mental handicap, membership in a reserve component of state or national military forces, or arrest or conviction record. No question on this application is intended to secure information to be used for any unlawfully discriminatory purpose.

I certify that the statements in this application are true and complete. I understand that any misstatement or omission of fact shall be sufficient cause for denial of employment or summary dismissal at any time during my employment. I consent to investigation by Beloit Health System of all information supplied by me and all references and previous employers to secure additional information. I release from any and all liability all representatives of Beloit Health System for their acts performed in good faith in connection with evaluation of my application, credentials and qualifications.

I understand that Beloit Health System is a drug and smoke-free environment, and that any offer of employment is contingent upon the satisfactory completion of a physical examination which includes a drug screen and investigation of my work record and references. I understand that nothing contained in this employment application, granting of an interview, any policies, procedures, or handbooks prepared by Beloit Health System creates an employment contract between Beloit Health System and myself. I understand that if I am employed by Beloit Health System, my employment can be terminated by either the Hospital or me at will, with or without cause, and with or without notice, at any time. No one other than the president of Beloit Health System has authority to make any agreement for employment which varies from the terms specified in this application.