GOOD SHEPHERD SERVICES, LTD.


EMPLOYMENT APPLICATION

This application is considered current until the position you have applied for has been filled. You must reapply for future openings. Qualified applicants receive equal consideration.  No question is asked for the purpose of excluding any applicant due to race, creed, color, national origin, religion, age, sex, handicap, disability, veteran status, marital status, sexual orientation, or any other characteristic protected by law. WE ARE AN EQUAL OPPORTUNITY EMPLOYER.

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Date:
Applicant Information

First Name:

Middle Name:

Last Name:

Street Address:

City:

State:

Zip Code:

Telephone: () -
Position for which you wish to be considered:
What source led you to make an application with us:

Employment History (start with present or most recent employer)

Company Name:

Telephone:
() -
Address:

City:

State:

Zip Code:

Employed from to

Supervisor: Pay-Start Last
Position & Responsibilities:
Reason for Leaving:

Company Name:

Telephone:
() -
Address:

City:

State:

Zip Code:

Employed from to

Supervisor: Pay-Start Last
Position & Responsibilities:
Reason for Leaving:

Company Name:

Telephone:
() -
Address:

City:

State:

Zip Code:

Employed from to

Supervisor: Pay-Start Last
Position & Responsibilities:
Reason for Leaving:

Education

High School
Name & City/State of School:
Major/Courses:
 		Last Year Attend:
 9 10 11 12
Diploma/License:

College/University
Name & City/State of School:
Major/Courses:
 		Last Year Attended:
 1 2 3 4 5
Diploma/License:

Technical/Trade
Name & City/State of School:
Major/Courses:
 		Month/Year Attended:
Diploma/License:

If you served in the U.S. Armed Forces, briefly describe the position and skills acquired:

Are you legally authorized to work in the U.S.? Yes No

 (NOTE: You will be required to furnish documents to verify your eligibility for employment in accordance with the Immigration Reform and Control Act and your employment is contingent upon furnishing such documents.)

Name, address and telephone number of someone other than a household member we can contact in case of an emergency:

Are you at least 18 years of age? Yes No
If not, your employment will be subject to verification that you meet state/federal minimum wage requirements for the type of work you are applying for and have obtained a valid work permit.

Have you ever been convicted of a crime or pleaded no contest for any offense or violation other than minor traffic violations? Yes No 

 A criminal record does not constitute an automatic barrier to employment. It will be considered only as it relates to the position in question. Federal regulation 483.13 (c)(l)(ii) prohibits health care organizations from hiring staff with a history of abuse of individuals.

Are you presently employed? Yes No
If so, may we contact your present employer? Yes No

Employment References
List individuals familiar with your job qualifications (no relatives or personal friends).

Reference Name:

Telephone:
() -
Address:

City:

State:

Zip Code:

Occupation:

Why is this person a good reference for you?

Reference Name:

Telephone:
() -
Address:

City:

State:

Zip Code:

Occupation:

Why is this person a good reference for you?

Reference Name:

Telephone:
() -
Address:

City:

State:

Zip Code:

Occupation:

Why is this person a good reference for you?

Authorization & Release

Please Read Carefully Before Submitting This Form

All information contained in this application is true and correct to the best of my knowledge and belief.  I understand that misrepresentations or omissions of any kind may result in denial of employment or be cause for subsequent dismissal if I am hired.

I authorize the company to investigate my responses on this application and contact any or all of my former employers or any individuals familiar with me or my employment background for the purpose of verifying any information I have provided and/or for the purpose of obtaining any information, whether favorable or unfavorable, about me or my employment.  I voluntarily and knowingly fully release and hold harmless any person or organization that provides information pertaining to me or my employment.

I understand that upon receiving a job offer, a physical examination and drug screening may be required. (Note: If this is a job requirement, you will be notified.)

Regardless of whether or not I become employed by the company, I recognize that this application is not and should not be considered a contract of employment.  I understand that employment at Good Shepherd Services is on an at-will basis and that my employment may be terminated with or without cause, and without notice, at any time, at my option or Good Shepherd Services', unless specifically provided otherwise in a written employment contract.  I further understand that no Good Shepherd Services employee or representative has the authority to enter into a contract regarding duration or terms and conditions of employment other than an officer, or official of Good Shepherd Services, and then only by means of a signed, written document.

I have read the above and approve: Yes No

Please e-mail this application to us, print it and mail it to us or call our Human Resources Department.

Good Shepherd Services, Ltd.
607 Bronson Road
Seymour, WI 54165
(920) 833-6856
mailto:swanta@goodshepherdservices.org
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