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SBL Fayette County Hospital
& Long Term Care

Application

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PERSONAL INFORMATION

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EDUCATION


Please list name of school, location, and degree


Please list name of school, location, and degree


Please list name of school, location, and degree


Please list name of school, location, and degree


EMPLOYMENT INFORMATION

Please provide complete work history information. Accurate compensation offers are based on applicable experience and education.

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Previous Employment











REFERENCES

Please provide at least two professional references.

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We are required to compile the following information for statistical purposes in order to fulfill certain federal regulations relating to Equal Employment Opportunity and Affirmative Action requirements. The information you provide is strictly voluntary, and the content of the information will not affect your eligibility for employment. Similarly, if you choose not to provide this information it will not affect your eligibility for employment.

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In submitting this application for employment, I understand that an inquiry may be made whereby information is obtained regarding my character, previous employment, general reputation, education, educational background and/or driving record. I attest that the information in this application is complete and accurate to the best of my knowledge. I authorize inquiry of all statements contained in this application and do hereby release and all persons, companies or agencies responding to such an investigation from any and all liability for damage due to releasing information pertaining hereto. Any misrepresentations or omission of facts in this application may result in my immediate discharge from employment or a revocation of an offer of employment. This application is in no way intended to be a contract. Any employment is contingent upon meeting SBL Fayette County Hospital standards for the placement which includes completion of the post-offer physical examination including urine drug screen, satisfactory results from reference checks, OIG sanction check, and Illinois State Police criminal background check. If you are covered by the Illinois Healthcare Workers’ Background Check Act, you may obtain a copy or the Criminal Conviction Report, challenge its accuracy, and/or request a waiver. It is the policy of SBL Fayette County Hospital to provide opportunities for employment to all qualified applicants according to federal and state law. Applicants are considered without regard to race, religion, gender identity, sexual orientation, age, national origin, veteran or disability.

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