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.

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

    Are you available to work:


    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:

    Employer 2:

    Dates Employed:

    Employer 3:

    Dates Employed:

    Employer 4:

    Dates Employed:

    NOTE TO APPLICANTS: Do not answer this question unless you have been informed about the requirements of the job for which you are applying.

    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.

    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.

    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.