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Online Application
Required Fields are marked with *
FACILITY SELECTION*  
Please select the facilities for which you wish to apply. If no facility is selected your Application will not be submitted.

SSFHS Corporate Office
(Mishawaka, IN)

PERSONAL INFORMATION  
In considering your application for employment, the facility may conduct a detailed and thorough investigation which may include, but is not limited to, a criminal record check, interviews or inquiries of prior employers, coworkers, acquaintances, relatives, or friends.
Last Name*
   		First*
 Middle*
Social Security No.*
For security purposes, we will request this information upon further consideration of employment 		Home Phone (with area code)*
 Other Phone
Email Address  
Present Address*
 City*
 State*
 Zip*
Permanent Address*
 City*
 State*
 Zip*
Any Previous Name(s)*
If yes, identify all other names under which employed 		Best Time to Contact You
 Date Available for Work
Position(s) Applied For
 What is your desired salary range?
  
Are you Applying for:*
Full Time: Part Time:
Registry/PRN: Temporary:
Would you consider working:*
Weekends Holidays
Rotating Shifts On Call
Any Shift Shift Preference:*
How did you learn about us?*
Other:

Do you have relatives or friends employed by this facility?*

Name Department Relationship

Have you ever been employed by this or another Sisters of St. Francis Health Services Facility?*

When? Where?
If you are under 18 years of age, can you provide required proof of your eligibility to work?
Are you a U.S. Citizen or alien legally authorized to work in the United States?*
(Proof of citizenship or immigration status will be required upon employment.)
Have you ever been subjected to any sanctions, penalties, or exclusions from any federal healthcare program (i.e., including but not limited to: Medicare, Medicaid, TriCare)?* If yes, explain:
Have you ever been convicted of, or pleaded guilty to a crime (excluding misdemeanor traffic violations)?* If yes, explain:
Have you ever been involved in the substantiated abuse or neglect of children or adults under the laws of this or any other state of the United States?*
If yes, explain:
If your answer is "yes" to either of the above, you will not be automatically disqualified from employment consideration, except as required by state or federal law.
Note to applicants: Do not answer this question unless you have been informed about the requirements of the job for which you are applying.
Are you capable of performing, with or without a reasonable accommodation, the essential functions of the job or occupation for which you have applied?

PERSONAL / PROFESSIONAL REFERENCES

Do not include family members or past supervisors.
Name Phone Number Best Time
to Call		 Occupation
1. * * *
2. * * *
3. * * *

WORK EXPERIENCE

Start with your most recent employment. Include any job-related military service assignments and volunteer activities. (You may exclude organizations which indicate race, color, religion, gender, national origin, disabilities, or other protected status.)
Employer (current) *
 Dates Employed
From * To *
Address (City, State, Zip) *
Starting/Present Job Title *
Salary Hourly Monthly Annually
* Supervisor Reason for Leaving
Work Performed
May we Contact?* Telephone Number(s)

Employer
 Dates Employed
From To
Address (City, State, Zip)
Starting/Present Job Title
Salary Hourly Monthly Annually
Supervisor Reason for Leaving
Work Performed
May we Contact? Telephone Number(s)

Employer
 Dates Employed
From To
Address (City, State, Zip)
Starting/Present Job Title
Salary Hourly Monthly Annually
Supervisor Reason for Leaving
Work Performed
May we Contact? Telephone Number(s)

Have you been discharged from any employment or asked to resign?
If yes, explain:
Comments (Explain any gaps in employment):

MILITARY EXPERIENCE
Were you a member of the U.S. Armed Forces?
Branch
Dates of Duty
 Type of Discharge
Briefly describe duties and any special training:

PROFESSIONAL TRADE, BUSINESS OR CIVIC ACTIVITIES
List professional, trade, business, or civic activities and offices held. (You may exclude memberships which would reveal gender, race, national origin, age, ancestry, disability, or other protected status.)

EDUCATION / SKILLS
Formal Education Name & Address of School (City, State) Course of Study Yrs. Completed Diploma/Degree
High School * * *
Undergraduate
College
Graduate
Professional

Specialized Skills (Skills / Equipment / Training)
Terminal Typewriter WPM
PC/MAC Shorthand WPM
Medical Terminology Word Processing WPM
Spreadsheet  
Languages (Other than English) that you read, write, or speak:
Other information you feel may be helpful to us in considering your application:
Computer Software Programs:

Professional Licenses / Registrations / Certifications
  Type State Date Number Have you ever been sanctioned or reprimanded by any state or federal healthcare agency or authority (including, but not limited to, a licensing agency)?

Driver's License (If driving is required for the position)
For security purposes, we will request this information upon further consideration of employment

I certify that the information contained in this application (and accompanying resume, if any) is true, correct and complete to the best of my knowledge. I also agree that any falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for termination if discovered at a later date.

I authorize a thorough investigation of my past employment, education and activities, agree to cooperate in such investigation, and release from all liability or responsibility all persons and/or entities requesting or supplying information from any damages that may result. I authorize Sisters of St. Francis Health Services, Inc. (SSFHS) to request and receive such information.

I understand that employment with SSFHS is at-will, which means that I may terminate the employment relationship at any time and for any reason with or without notice, and that SSFHS has the same right. I understand that no one may alter the at-will nature of my employment except the President/CEO, or designee, and then only in a written and notarized agreement. I understand that if I am employed, I will conform to the rules and regulations of SSFHS.

I acknowledge that these rules and regulations may be changed, interpreted, withdrawn, or added to by SSFHS at any time at the company's sole option and without any prior notice to me.

I understand that an offer of employment is contingent upon satisfactory completion/result of the following: a post-offer medical examination (including lab work and drug screening); a reference, background and criminal history check; integrity and/or skills testing; proof of legal authority to work in the United States under federal immigration laws; and completion of the introductory period.

I acknowledge being advised that this application will remain active for no more than 6 months from the date it was made. Submission of this application neither automatically results in an employment interview nor a job offer. SSFHS is an Equal Opportunity Employer.

Keying your name below on the signature line is equivalent to signing your name to this document and therefore conveys your acknowledgement and authorization of the above statements.

* Signature of Applicant * Date:
HR Representative Date:

"I acknowledge that I am forwarding this application to SSFHS electronically and that I have agreed to conduct this transaction electronically. I further agree that SSFHS may respond to this application electronically."