Personal Information
Facility Interested In
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Name*
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Email*
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Address*
Street Address City State ZIP Code
Primary Phone*
Secondary Phone
Other Information
Position Desired
Professional License / Certification Number
Type
State
Where currently Employed
Have you ever been employed by a health care facility?
- Yes
- No
If Yes, which facility?
May we share this application with others?
- Yes
- No
Education
Name of School/College Major Subject Degree Earned

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Former Employers & Experience (References)
Place of Employment Address Phone Number Dates Employed Reason for Leaving

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Personal References
Reference Name Phone Business

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Any Additional Comments
Optional Self-Identification
Submission of this information is voluntary and refusal to provide it will not subject you to any adverse treatment. The information will be kept confidential and will only be used in accordance with the provisions of applicable laws, executive orders, and regulations, including those that require the information be summarized and reported to the federal government for civil rights enforcement. When reported, data will not identify any specific individual.
Gender
- Male
- Female
Race/Ethnicity (Check all that apply)
- Asian/Pacific Islander
- American Indian/Alaskan Native
- Hispanic/Latino
- Black/African American
- White
Military Status (Select One)
- Active Reserve
- Armed Forces Service Medal Veteran
- Inactive reserve
- No Military Service
- Other Protected Veteran
- Service Medal and Other Veteran
- Veteran (VA Ineligible)
- Veteran of the Vietnam Era
- Vietnam and Other Protected Veteran
- Retired Military
Confirmation
Confirmation*
- I understand that Petersen Health Care is An EQUAL OPPORTUNITY EMPLOYER. I understand that I will be required to have a physical examination if employed. I understand that if I have falsified any information on this application, and enter into employment Petersen Health Care, I may be immediately terminated upon discovery of the falsification. Petersen Health Care may seek references from the list above. All employees of Petersen Health Care will be subject to an Illinois State Police background check. Employees requiring State Certification and registration on the Illinois Healthcare Workers Registry will be required to have and ISP “fingerprint background check” at no cost to the employee. Non-certified staff not requiring licensure by the Illinois Department of Professional Regulation will be required to have an ISP “fingerprint background check”. I understand that the $30 cost of that background check will be deducted from my first paycheck when required. No person may be employed by Petersen Health Care if he/she has been convicted of any offense listed in the Illinois Healthcare Worker’s Background Check Act.
Field Count

Name of School/College	Major Subject	Degree Earned

Place of Employment	Address	Phone Number	Dates Employed	Reason for Leaving

Reference Name	Phone	Business

MDS / Care Plan Coordinator

MDS / Care Plan Coordinator

Personal Information

Other Information

Optional Self-Identification

Confirmation

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