Application for Employment "*" indicates required fields Name* First Middle Last Date MM slash DD slash YYYY Phone Number*Email* Present Address: Are you legally eligible for employment in the USA?* Yes No In the past three years, have you lived in any other states other than WI?* Yes No If yes, give states and dates Are you able to accept a position that requires: a. Driver’s license?* Yes No b. Use of your automobile?* Yes No Position applying for?* What days and hours are you available to work? *Sunday Monday Tuesday Wednesday Thursday Friday Saturday Would you work Full time Part time Are you at least 18 years of age?* Yes No Were you previously employed by us?* Yes No If yes, when If your application is considered favorably, on what date will you be available for work?* Were you referred to us by a current SM2 Services employee?* Yes No If yes, who: Have you ever been convicted of a crime?* Yes No If yes, please explain.Have you ever been found guilty of caregiver misconduct?* Yes No If yes, please explain. WORK EXPERIENCE Please list all of your employers for the past ten years. Begin with the most current employer. Attach additional pages, if necessary. I.Employer: Position: City/ State: Phone:Employed from: to Supervisor: Description of Duties:Reason for Leaving: May we contact this employer?* Yes No II.Employer: Position: City/ State: Phone:Employed from: to Supervisor: Description of Duties:Reason for Leaving: May we contact this employer?* Yes No III.Employer: Position: City/ State: Phone:Employed from: to Supervisor: Description of Duties:Reason for Leaving: May we contact this employer?* Yes No IV. Employer: Position: City/ State: Phone:Employed from: to Supervisor: Description of Duties:Reason for Leaving: May we contact this employer?* Yes No RECORD OF EDUCATIONSchoolHigh SchoolName/Address Last Year Completed 1 2 3 4 Did you graduate? Course of Study CollegeName/Address Last Year Completed 1 2 3 4 Did you graduate? Course of Study Other (specify)Name/Address Last Year Completed 1 2 3 4 Did you graduate? Course of Study List any skills and/or training that you have related to the position applying forPERSONAL REFERENCES (Do not include relatives)Name Occupation Telephone #Number of Years Known Name Occupation Telephone #Number of Years Known Name Occupation Telephone #Number of Years Known IMPORTANT, PLEASE READ AND SIGN: I hereby affirm that all statements are accurate, complete, and true to the best of my knowledge. I understand that if I knowingly give false information, I will not be eligible for employment with this agency. I authorize any person, school, current and past employer, and organizations named in this application to provide this agency with any information connected with this application, and I release such persons and organizations from any legal liability in making such statements. I understand that a background check may include an internet search. In addition, I acknowledge that at any time during employment, a motor vehicle record report, or criminal history evaluation may be required if there is reasonable cause to believe the qualification requirements have not been met. Failure to comply with any of these requirements may result in immediate separation from employment with this agency. I understand that if I am considered for employment, I will have to furnish proof of my eligibility to be employed in the United States. Furthermore, I understand that if I am considered for employment, I will be required to pass a caregiver and criminal background check. I understand that nothing in this application or in any prior or subsequent written or oral statement creates a contract of employment or any rights in the nature of a contract. I agree and understand that if I am hired by the agency my employment will be “at will”, for an indefinite period of time, and may be terminated at any time, with or without cause or notice, at the option of the agency or myself. This application will be valid for 60 days from the date of submission, at which time a new application must be completed. Acknowledgement I certify that I have read and acknowledge the above information Signature*Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
