APPLICATION FOR EMPLOYMENT

Homme Home of Wittenberg is an equal employment opportunity employer dedicated to a policy of non-discrimination in employment based upon an individual’s race, color, creed, religion, age, sex, national origin, ancestry, marital status,sexual orientation or the presence of any non-job-related medical condition or disability. In reading and answering the following questions, please keep in mind that none of the questions are intended to imply any limitations, illegal preferences, or discrimination based upon any non-job-related information. This application will be given consideration, but its receipt does not imply that the applicant will be interviewed or employed. Please contact Human Resources if you need an accommodation to participate in the application process at 715-253-2125.

 

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YesNo

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Proof of citizenship or immigration status will be required upon employment.

Are you available to work:

123Shift

MorningsAfternoonEvenings

YesNo


EDUCATION
School/High School

Undergraduate College

Graduate/Professional

Other (Specify)


WORK EXPERIENCE
Start with your present or last job. 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 1







Dates Employed


Hourly Rate / Salary


May we Contact YesNo
 
Employer 2







Dates Employed


Hourly Rate / Salary


May we Contact YesNo
 
Employer 3







Dates Employed


Hourly Rate / Salary


May we Contact YesNo
 
Employer 4







Dates Employed


Hourly Rate / Salary


May we Contact YesNo

Include explanation of any gaps in employment.

Describe any specialized training, apprenticeship, skills and extra-curricular activities.

Describe any job-related training received in the United States Military.

List professional, trade, business or civic activities and offices held.

Additional Information Other Qualifications

Specialized Skills (check skills and certification)
Typewriter/KeyboardSpreadsheetWord ProcessingData Base

Certified Nursing Assistant    

Licensed Practical Nurse    

Registered Nurse    

Medication Aide    

Personal Care Attendant    

Other (list)


State any additional information you feel may be helpful to us in considering your application.

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 in a reasonable manner, with or without a reasonable accommodation, the activities involved in the job or occupation for which you have applied? A review of the activities involved in such a job or occupation has been given. YesNo

Personal/Professional References Do not include family members or past supervisor.
Reference 1


Reference 2


Reference 3



APPLICANTS STATEMENT
Please check that you have read and understand the following statements.

I promise that the information provided in this employment application (and accompanying resume, if any) is true and complete, and I understand that any false information or significant omissions may disqualify me from further consideration for employment, and may be justification for my dismissal from employment by Homme, Inc. of Wisconsin if discovered at a later date. I agree to immediately notify Homme if I should be convicted of a felony, or any crime involving dishonesty or a breach of trust while my job application is pending, or during my period of employment, if hired.

I authorize any person, school, current employer (except as previously noted), past employer(s), government or investigative agencies, and other organizations that may be named in this application form (and accompanying resume, if any) to provide Homme with relavant information and opinion that may be useful to Homme in making a hiring decision, and I release such persons and organizations from any legal liability in making such statements.

If offered a job, I give permission for a job-related complete physical examination, and I consent to the release to Homme of any medical information, as may be deemed necessary by Homme in judging my capability to perform the essential functions of the work for which I am applying (with or without a reasonable accommodation).

I understand that, if hired, I may not hold other employment, nor engage in consulting, sales, investments or other activities that may create a conflict of interest with Homme.

I understand that if employed and my employment is terminated by Homme for dishonesty, breach of trust, or any criminal acts, the authorities may be notified and I may be criminally prosecuted.

I understand that this application does not, by itself, create a contract of employment. I understand and agree that, if hired, my employment is for no definite period of time, and may, regardless of the date of payment of my wages or salary, be terminated at any time. I understand that only the Administrator of Homme is authorized to change any of the terms of employment and that any changes must be specific and in writing.

Signature:    Date: (Format: YYYY-MM-DD)


APPLICANT DATA RECORD

Applicants are considered for all positions, and employees are treated during their employment without regard to their race, color, creed, religion, sex, national origin, age, marital status, sexual orientation, military status, any non-job-related handicap or medical condition, or any other legally protected status.

As an employer taking affirmative action to ensure the removal of any possible past discrimination and to help comply with governmental record-keeping requirements, we would appreciate your completing this form. This data will be physically separated from the remainder of your job application before the application is considered for possible employment. This information will be kept in a confidential file, separate from your application for employment.

Check One:
WhiteBlack / African AmericanHispanicAsian/Pacific IslanderAmerican Indian/Alaskan Native

How were you Referred to our Company?
Saw Newspaper AdvertisementA Private Employment AgencyA Relative or Friend Employed by this CompanyOther

Check any that Apply: Vietnam Era VeteranDisabled VeteranHandicapped Person

AUTHORIZATION FOR PRE-EMPLOYMENT SCREENING
As part of your pre-employment screening, the following information will be gathered to help determine your suitability for the position for which you have applied: Reference Checks from at least two (2) sources; Background Information Disclosure HFS-64; and current licensure if applicable. I hereby authorize Homme, Inc. of WI to proceed with my pre-employment screening to obtain the information as noted above. I release Homme and my former employers from any liability arising therefrom.

Signature:    Date: (Format: YYYY-MM-DD)

Please attach resume here: