Employment

First Name

Middle Initial

Last Name

Street Address

City

State

Zip Code

Phone

Position Applied For

Available Start Date

Desired Salary

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Are you a legal U.S. Resident employable in the United States?

Have you previously been employed by Sunset Ridge Jefferson?

If yes, give dates

Sunset Ridge Jefferson provides care for our residents twenty-four hours a day, seven days per week. All staff members are required to work weekends and holidays on a rotating basis. You may also be asked to fill in for absent co-workers on an on-call basis. Are you available for work under these conditions?

List your employers starting with your present or most recent.

Employer Information #1

Employer Name

Employer Address

Supervisor's Name

Employment Dates

Job Title

Starting Salary

Ending Salary

Reason for Leaving

List Job Duties and Responsibilities

May we contact this employer?

Employer Information #2

Employer Name

Employer Address

Supervisor's Name

Employment Dates

Job Title

Starting Salary

Ending Salary

Reason for Leaving

List Job Duties and Responsibilities

May we contact this employer?

Employer Information #3

Employer Name

Employer Address

Supervisor's Name

Employment Dates

Job Title

Starting Salary

Ending Salary

Reason for Leaving

List Job Duties and Responsibilities

May we contact this employer?

List any job or volunteer experience that you feel qualifies you for this position

Highest level of education completed?

School Name

School Address

Do you have certification (DHS 83 approval number course) in any of the following: (Check all that apply)

Fire Safety

First Aid

Medications

Dietary Needs

Block I (any unit)

Standard Precautions

CNA

PCW

Other…

Do you have any other certifications?

Do you have any restrictions that would prohibit you from performing the duties required for this position, or are you in need of any special accommodations?

If Yes, Explain

Have you ever been convicted of a crime or felony?

If Yes, Please Give Convictions and Dates

Please List 3 Professional References:

Reference #1

Name

Relationship

Company

Phone Number

Reference #2

Name

Relationship

Company

Phone Number

Reference #3

Name

Relationship

Company

Phone Number

Disclaimer

Sunset Ridge Jefferson operates under the philosophy of non-discrimination for all employees regardless of race, origin, color, religion, gender, marital status, sexual preference, veteran status, or disability. Employment decisions will be made on the basis of competency to state or national licensure and/or certification. A criminal background check is required by the State of Wisconsin, the results of which may prohibit employment under State of Wisconsin DHS 83 regulation. By DHS 83 regulation, all employees are required to be at least 18 years of age.

I certify that my answers are true and complete to the best of my knowledge. I authorize Sunset Ridge Jefferson to investigate this information by contacting my present or former employers and listed references.
If this application leads to employment, I understand that false or misleading information in my application or interview may result in my release.
By typing my name below I agree to this disclaimer, and acknowledge that all answers given here in, are true statements.

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