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ABC of Wisconsin

Employment Application Form

Employment Application Form

ABC of Wisconsin, Inc. is an equal opportunity employer and does not discriminate on the basis of age, race, creed, color, handicap, marital status, sex, national origin, ancestry, sexual orientation, arrest or conviction record, or veteran status.

Name:(Required)

First Last

Present Address:(Required)

Street Address City State Zip

Is your permanent address the same?(Required)

Yes

No

Permanent Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone number:(Required)

Email address:(Required)

Are you able to perform, with or without reasonable accommodation, the job functions of the positions for which you are applying?

Yes

No

Are you a U.S. citizen or otherwise currently authorized to obtain lawful employment in this country?(Required)

Yes

No

Are you 18 years of age or older?(Required)

Yes

No

If the job desired requires the use of a motor vehicle, do you have a valid driver's license?(Required)

Yes

No

Have you ever pleaded guilty to or been convicted of a misdemeanor or felony or are you subject to any pending criminal charges? A “yes” answer will not automatically disqualify you from employment.(Required)

Yes

No

Please provide further information as to the offense(s)/charge, date, located of court, and so forth. If the job you are applying for requires you to operate a motor vehicle, include traffic convictions. We will consider your record only as it may substantially relate to the job for which you are applying and only as permitted by applicable law.

Employment Desired

Position(s) applying for:(Required)

Is this position full time or part time?

Full Time

Part Time

Date you can start:

MM slash DD slash YYYY

Rate of pay you expect to earn (please indicate hourly or annually)?

Have you filed for an application of employment with us before?(Required)

Yes

No

Indicate special qualifications or skills:

EDUCATION

List your educational experience which you believe is relevant for the position you are applying for.

High school name and location:

High school years completed:

Did you graduate?

Yes

No

High school courses of study:

College name and location:

College number of years completed:

Did you graduate?

Yes

No

College courses of study:

Other education name and location:

Other education number years completed:

Did you earn a degree/diploma/certificate?

Yes

No

Other education courses of study:

Please provide any other training, education or experience relevant to the position for which you are applying:

EMPLOYMENT HISTORY

Provide complete information. Be specific. Start with your current or most recent job. Include self-employment and military service. For part-time work, show the average number of hours per month.

Employer 1

Employer company/organization name:

Employer street address, city, state, zip:

Employer phone number:

Your position/title:

Was this full time or part time?

Full time

Part time

How many hours per month on average?

Your duties:

Work dates from mm/yyyyy to mm/yyyyy:

Last rate of pay/salary:

Reason for leaving?

Employer supervisor name:

Employer 2

Employer company/organization name:

Employer street address, city, state, zip:

Employer phone number:

Your position/title:

Was this full time or part time?

Full time

Part time

How many hours per month on average?

How many hours per month on average?

Your duties:

Work dates from mm/yyyyy to mm/yyyyy:

Last rate of pay/salary:

Reason for leaving?

Employer supervisor name:

Employer 3

Employer company/organization name:

Employer street address, city, state, zip:

Employer phone number:

Your position/title:

Was this full time or part time?

Full time

Part time

How many hours per month on average?

Your duties:

Work dates from mm/yyyyy to mm/yyyyy:

Last rate of pay/salary:

Reason for leaving?

Employer supervisor name:

References

Names of those you’ve worked with at previous employers or volunteer organizations. These individuals should not be related to you. Please provide at least one supervisor.

Reference 1

Reference 1 full name:

Address:

Email address:

Telephone Number:

Person's occupation/business:

Was this person your supervisor?

Yes

No

Reference 2

Reference 2 full name:

Address:

Email address:

Telephone number:

Person's occupation/business:

Was this person your supervisor?

Yes

No

Reference 3

Reference 3 full name:

Address:

Email address:

Telephone number:

Person's occupation/business:

Was this person your supervisor?

Yes

No

AUTHORIZE, RELEASE AND CERTIFICATION

I certify that all information on this application is true and correct to the best of my knowledge. I understand that any false or misleading statements or omissions by me may result in rejection of my application or if employed my immediate dismissal. I hereby give permission to the employer to seek to verify and supplement the information set forth in the application. I release from all liability or legal claims every person seeking or providing information, whether oral or written. A photocopy of this release shall be valid as the original and may be relied upon by all persons providing information. I understand that employment with this employer is not contractual and is at-will. I understand and agree that if hired I may voluntarily leave employment at any time and may be terminated at any time without prior notice for any reason or for no reason. I understand that any oral or written statements which I may claim to have been made to me now or in the future inconsistent with the provisions of this paragraph, are expressly disavowed and revoked by the company and should not be relied upon by me as an applicant for employment or as an employee, if hired, unless such statement is in the form of an express written document with the title “Employment Contract” signed by the President of the Association. I understand this application will be considered inactive after thirty days. I certify I have read (or have had read to me) and understand this authorization, release, and certification.

Acceptance & Signature(Required)

I agree to the above conditions and to ABC of Wisconsin, Inc. Privacy Policy

Signature:

Date:

Month

Day

Year

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