| * Position Applying for |
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| * Date |
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Please indicate the counties you will be willing to work in: |
Brown
Fond du Lac
Outagamie
Shawano
Waupaca
Winnebago |
Referral Source |
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| * First Name |
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| Middle Initial |
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| * Last Name |
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| * Street Address |
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| * City |
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| * State/Province |
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| * Zip/Postal Code |
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| 10 Digit Home Phone |
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| Cell Phone |
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| Work Phone |
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| * Best time to call |
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| Are you 18 or older |
Yes
No
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| Have you filled an application here before? |
Yes
No
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| Have you ever been employed here before? |
Yes
No
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| Are you legally eligible for employment in this country |
Yes
No
(Proof of U.S. citizenship or immigration
will be required upon employment.) |
| Type of employment desired: |
Full-time
Part-time
Either
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| * Date available to start work: |
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| Have you been convicted of a
felony or misdemeanor in the last seven years? |
Yes
No
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| If
yes, please state date, place and nature of convictions: |
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| Do you have a valid drivers license? |
Yes
No
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| Do you have auto insurance |
Yes
No
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List your last three (3) employers, assignments or
volunteer activities,
starting with the most recent, including military
experience. |
| |
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| * Employer 1 |
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| Phone |
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| Street, City, State & Zip |
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| Job Title |
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| Immediate Supervisor and Title |
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| Reason for leaving |
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| May we contact for reference |
Yes
No
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| Dates employed from |
to
(mm/dd/yy)
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| Hourly rate/ Salary starting |
$
Per
|
| Ending |
$
Per
|
| Summarize the nature of the work performed and job
responsibilities: |
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| |
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| Employer 2 |
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| Phone |
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| Street, City, State & Zip |
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| Job Title |
|
| Immediate Supervisor and Title |
|
| Reason for leaving |
|
| May we contact for reference |
Yes
No
|
| Dates employed from |
to
(mm/dd/yy)
|
| Hourly rate/ Salary Starting |
$
Per
|
| Ending |
$
Per
|
| Summarize the nature of the work performed and job
responsibilities: |
|
| |
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| Employer 3 |
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| Phone |
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| Street, City, State & Zip |
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| Job Title |
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| Immediate Supervisor and Title |
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| Reason for leaving |
|
| May we contact for reference |
Yes
No
|
| Dates employed from |
to
(mm/dd/yy)
|
| Hourly rate/ Salary Starting |
$
Per
|
| Ending |
$
Per
|
| Summarize the nature of the work performed and job
responsibilities: |
|
| |
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| Educational Background |
(this section is
optional) |
High School
School/Location |
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| Did You Graduate? |
Diploma
GED
HSED
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Technical/ College/
University/Location |
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| Number of years completed |
1
2
3
4
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| Degree or Diploma |
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| Minor |
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| |
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Professional/Trade Certification or Licenses |
| Certification/License |
Date |
Issued By |
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EMPLOYEE RESPONSIBILITY TO THE ORGANIZATION:
Please be sure to read the following statements carefully
I certify that all the
information I have provided on this application is true and complete to the
best of my knowledge. I understand that omitting requested information or
giving false information on my application in my interview (s) or in the
process of my pre-employment evaluation may result in rejection of my
application, withdrawal of a job offer, or termination, if I am hired.
I authorize investigation
of all statements in this application as may be necessary in arriving at an
employment decision, including a police/criminal record check from the
Wisconsin Department of Justice or any other appropriate Agency(s). I hereby
release from liability the employer'(s) and its representatives for seeking
and furnishing such information.
I understand that if
offered a job, I will be required to:
- Undergo a physical health exam and
communicable disease screening by a physician designated by the
Employer, which may affect decisions whether I can do the essential
functions of the job.
- Undergo and pass a criminal record,
driving record and references checks
- And, after placement, complete and
receive certification in any and all employee training required and
requested by the Employer. I understand this training needs to be
competed within the first 90 days of employment and is a condition for
continued employment.
I understand that the
organization is an equal opportunity employer. The employer does not
discriminate in employment and no question on this application is used for
the purpose of limiting for excluding any applicant’s consideration for
employment on any basis prohibited by local, state or federal law.
I understand that this
application does not represent an offer of, or contract for, employment. I
understand that employment with this company is “at will,” and that no
guarantee of job exists. If employed, I may terminate employment at any time
for any reason, and the company may terminate my employment at any time for
any reason not contrary to law.
This application is current
for only (60) days. At the conclusion of this time, if I have not heard from
the employer and still wish to be considered for employment, it will be
necessary for me to fill out a new application.
* I have read and agreed to the above statement.
