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.

Positions Applied For (required):

Date of Application (required):

Your Name (required):

Address (required):

City (required):

State (required):

Zip Code (required):

Telephone Number (required):

Best Time to contact you:

Your Email (required):

If you are under 18 years of age, can you provide required proof of your eligibility to work? (required):YesNo
Have you ever filed an application with us before?:YesNoIf Yes, give date:
Have you ever been employed with us before?:YesNoIf Yes, give date:
Do any of your friends or relatives, other than spouse, work here?:YesNoIf Yes, state name, relationship and location:

Are you currently employed?: YesNo
May we contact your present employer?: YesNo
Are you prevented from lawfully becoming employed in this county because of Visa or Immigration Status?: YesNo

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

Date available for work (required):
What is your desired salary range? (required):

Are you available to work:

Full Time123Shift
Part TimeMorningsAfternoonEvenings
Temporary (Please indicate dates available):
Are you currently on "lay-off" status and subject to recall?: YesNo

Education

School/High School:

Undegraduate 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:

From:
To:
Hourly Rate/Salary:

May we contact this employer?: YesNo

Employer 2:

Dates Employed:

From:
To:
Hourly Rate/Salary:

May we contact this employer?: YesNo

Employer 3:

Dates Employed:

From:
To:
Hourly Rate/Salary:

May we contact this employer?: YesNo

Employer 4:

Dates Employed:

From:
To:
Hourly Rate/Salary:

May we contact this employer?: 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 & certification)
Typewriter/KeyboardSpreadsheetWord ProcessingData BaseCertified Nursing AssistantLicensed Practical NurseRegistered NurseMedication AidePersonal Care AttendantOther

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:

Applicant 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 (required):
Date (required):

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/AfricanAmericanHispanicAsian/PacificIslanderAmericanIndian/AlaskanNative
How were you Referred to our Company?:
Newspaper AdvertisementPrivate Employment AgencyRelative 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 (required):
Date (required):

Please attach your resume here:

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