Employment Application Augusta Health and Rehabilitation,901 Bridge Creek Lane, Augusta WI 54722Application for Employment• No question on this form is asked for the purpose of limiting or excluding any applicant’s consideration because of race, color, sex, national origin, age, marital status, creed, disability, ancestry, arrest or conviction record, sexual orientation or status regarding public assistance. Thank you for your interest in employment with us.• This application will be retained in our active file for 6 months. If you have not been employed within this period and are still interested in employment at Augusta Health and Rehabilitation, please contact the office and request your application be reactivated.• A copy of the job description for the job for which you are applying, which identifies the essential functions of the job, is available upon request.• If you are offered a job with Augusta Health and Rehabilitation, (1) you may, depending on the particular job you are offered, be required to take a physical exam at our expense, to determine if you are physically capable, with or without accommodation, of performing essential functions of the job and (2) you will be asked to provide your full name, sex, race and date of birth to allow us to obtain information from the State Crime Information Bureau. Federal law prohibits health care facilities from hiring individuals convicted of abusing, neglecting, or mistreating other individuals in a health care or related setting. Augusta Health and Rehabilitation is required to make a reasonable effort to uncover information about any past criminal prosecution.• Any job offer made by Augusta Health and Rehabilitation is contingent upon a satisfactory physical examination, if required, and a report from the Crime Information Bureau.NamePosition Applied ForStreet AddressTelephoneReferral SourceAre you 18 years of age or older?YesNoIf available for more than one shift, number by order of preference. Example: Days _1_ PM’s _2_, etc.Shift preference:DaysPM’sNightsOn CallAvailable SaturdaysSundaysCheckboxFull timePart timeTemporaryOtherType of employment:Date Available to WorkDo you have commitments or responsibilities that might prevent you from meeting attendance requirements or that might require lengthy absence from work?Other names under which you have been employedName and relationship of relatives employed at Augusta Health and RehabilitationEducationName and Location of High School# Years CompletedDid you graduate?Course of StudyDegreeName and Location of College# Years CompletedDid you graduate?Course of StudyDegreeName and Location of School (Other)# Years CompletedDid you graduate?Course of StudyDegreeList any special skills or qualificationsHave you ever pled “guilty”, “no contest” to, or been convicted of a crime?YesNoIf yes, please provide dates and detailsHave you ever been employed by Augusta Health and Rehabilitation?YesNoIf yes, give dates and locationsHave you ever submitted an employment application with Augusta Health and Rehabilitation?YesNoIf yes, when and for what positionAre you legally eligible for employment in this country?YesNoAre you presently employed?YesNoIf so, may we contact your present employer?YesNoEmployment RecordList every employment whether or not it seems relevant to the position applied for. If lapses occurred between periods of employment, give dates of and reason for unemployment. LIST MOST RECENT POSITION FIRSTEmployerLocationTelephoneSupervisorEmployed fromtoJob TitleDescription of dutiesReason for leavingEmployerLocationTelephoneSupervisorEmployed fromtoJob TitleDescription of dutiesReason for leavingEmployerLocationTelephoneSupervisorEmployed fromtoJob TitleDescription of dutiesReason for leavingAdditional details: Please list any additional employment not shown above, or any information you believe would be helpful to us. (You may exclude all information indicative of age, sex, race, religion, color, national origin, marital status or disability.)ReferencesDo not list former employers or relativesNameTitleTelephoneNameTitleTelephoneTitleNameTelephone• I hereby declare the information provided by me in the Application for Employment (and accompanying resume, if provided) is true, correct and complete to the best of my knowledge. I understand that if employed, any misstatement or omission of fact on this application shall be considered cause for dismissal. I understand that Augusta Health and Rehabilitation reserves the right to withdraw any job offer• I understand that my employment can be terminated, with or without cause, at any time, at the discretion of either Augusta Health and Rehabilitation or myself. I understand that no management official other the Executive Team has any authority to enter into any agreement contrary to the foregoing or make any oral assurance of promise of continued employment.• I authorize persons, schools, my current employer (if applicable), and previous employers and organizations named in this application (and attached resume, if any) to provide relevant information that may be required to arrive at an employment decision.SignatureYour browser does not support e-Signature field.Date Send Message