Employment Application Please fill out our employment application below. Employment Application Personal InformationName* First Middle Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Alternate PhoneEmail* List any names used if different on this application Position Applying For? I am Seeking* Full Time Part Time Date available to start work:* Desired Salary Are you at least 18 years of Age?* Yes No Are you legally authorized to work in the US?* Yes No Are you a Veteran?* Yes No Are you a present member of the National Guard or Reserves?* Yes No Do you have a valid driver's license?* Yes No Have you ever been convicted of a felony?* Yes No If “Yes” please explain in concise detail below, giving dates and nature of the offense.NOTE: A “Yes” answer to the above question does not necessarily disqualify an applicant for employment.Are you employed at the present time?* Yes No If employed are we able to contact your present employer? Yes No Have you ever applied or worked with our agency in the past?* Yes No Do you have a valid WI driver’s license in good standing?* Yes No What is your driver’s license number? When does your driver’s license expire? Can you provide proof of vehicle insurance?* Yes No What shifts are you willing to work?* Any Day Night Overnight Are you willing to work on Holidays?* Yes No Are you willing to work on Weekends?* Yes No Are you available for overtime hours if required?* Yes No What days are you unable to work? Are you able to meet the attendance requirements of the position?* Yes No Have you been referred to Community Alternatives?* Yes No If yes, who referred you? EMPLOYMENT HISTORYList most recent employment first. Include summer or temporary jobs. Be sure all your experience or employers related to this job are listed here, in the summary following this section or on an extra sheet of paper, if necessary. No more than 10 years of employment history is recommended.Employer / Company Name* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Name:* Phone*Job Title* Dates of Employment* Description of Primary Responsibilities:*Duties/SkillsRate of Pay Reason for Leaving Employer / Company 2 Name* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Name:* Phone*Job Title* Dates of Employment* Description of Primary Responsibilities:*Duties/SkillsRate of Pay Reason for Leaving Employer / Company 3 Name Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Supervisor Name: PhoneJob Title Dates of Employment Description of Primary Responsibilities:Duties/SkillsRate of Pay Reason for Leaving Which of the jobs listed in your employment history did you like best? Which of the jobs listed in your employment history did you like the least? EducationHigh School Name* High School Address* Year Completed* Field of Study or Degree* Graduated* Yes No College/University Name College/University Address Field of Study or Degree Graduated Yes No Business/Technical Business/Technical Address Field of Study or Degree Graduated Yes No Any Additional EducationPlease specify Name & Address, Years Completed, Field of Study or Degree ObtainedReferencesName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneBusiness Years Known Relationship Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneBusiness Years Known Relationship Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneBusiness Years Known Relationship Skills & QualificationsPlease list any special Training/Skills/Qualifications - List all job related training or skills you possesses such as personal abilities, honors, professional licenses, certifications, First Aid, CPR, Fire Safety, Medication Administration , Resident Rights or registrations that should be considered :Do you speak or write a language other than English (if required for this job)?* Yes No If yes, which other languages to your speak? Do you have any sign language experience (if required for this job)? Yes No PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY➢ Non-discrimination policy: Community Alternatives does not discriminate in hiring or employment on the basis of race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation and any other protected categories. No question on this application is intended to secure information to be used for such discrimination. ➢ I hereby certify that the information contained in this application form is true and correct to the best of my knowledge and agree to have any of the statements checked by Community Alternatives unless I have indicated to the contrary. I understand that any misrepresentation, falsification, or material omission of information on this application may result in my failure to receive an offer, or if I am hired, in my dismissal from employment. ➢ In consideration of my employment, I agree to conform to the rules and standards of Community Alternatives, as amended from time to time at Community Alternatives’ sole discretion. I understand that in accepting this application, Community Alternatives is in no way obligated to provide me with employment and that I am not obligated to accept employment if offered. Furthermore, if employed, I understand that I am employed at will and that my employment and compensation can be terminated with or without cause, and with or without notice at any time. ➢ I understand that no employee or representative of Community Alternatives has any authority to enter into any agreement for employment for any specified period of time, or to make any agreement contrary to the foregoing. I also understand that all offers of employment are contingent upon proof of my identity, legal ability to work in the United States, successful completion of pre-employment screening and satisfactory reference checks. ➢ I authorize Community Alternatives to investigate any information, including my employment history, educational background, credit history and record of criminal convictions that it believes is relevant to my employment application. My former employers, education institutions, and personal references may provide information that they may have about me in response to inquiry from Community Alternatives. I also understand that any offer of employment is conditioned on the completion of pre-employment tests, background checks and documentation. I will, upon request, sign all necessary consent forms.Digital SignatureI understand that all inquiries on this application must be completed and if any inquire is left blank, my application will be rejected. I also acknowledge that I have read and understand all of the above statements and hereby grant permission to confirm the information supplied on this application by me. Signature Date* MM slash DD slash YYYY Signature*CAPTCHA