Job Details
Have you ever **worked** Yes No If yes, which location have you worked at: Have you ever **applied** Yes No If yes, which location have you applied at: List any additional trades or qualifications you may have for the position you have applied for: Please list, in order of preference, the position(s) for which you wish to be considered: Expires: State: Years: Months: Date Available for Employment:
Date: Salary/Wage Desired: Number of desired hours per week: Position(s) held and major job duties: Yes No **Background Information Disclosure**
. Completion of this form is required under the provisions of Chapters 48.685 and 50.065, Wis. Stats. Failure to comply may result in a denial or revocation of your license, certification, or registration; or denial or termination of your employment or contract. Refer to the instructions for additional information. Providing your social security number is voluntary; however, your social security number is one of the unique identifiers used to prevent incorrect matches.
*NOTE: If you are an owner, operator, board member, or non-client resident of a Division of Quality Assurance (DQA) facility, complete the BID, F-82064, and the , and submit both forms to the address noted in the Appendix Instructions.*
**Applicant Information**
Check the box that applies to you:
Employee/Contractor (including new applicant) Applicant for a license or certification or registration (including continuation or renewal) Household member/lives on premises - but not a client Other If other, please specify: First Name: Last Name: Title: Any other names by which you have been known (Including maiden name, separate multiple by commas): Birth Date: Gender: Race: Address (Street, City, State, Zip): Social Security Number: Business Name and Address: **Acts, Crimes, and Offenses That May Act As A Bar Or Restriction**
Yes No *NOTE: A response to this question is only required for group and family day care centers for children and day camps for children.)* Yes No Yes No Yes No Yes No Yes No Yes No **Other Required Information**
Yes No Yes No Yes No Yes No Yes No **A "NO" answer to all questions does not guarantee employment, residency, a contract, or regulatory approval.**
I understand, under penalty of law, that the information provided above is truthful and accurate to the best of my knowledge and that knowingly providing false information or omitting information may result in a forfeiture of up to $1,000.00 and other sanctions as provided in DHS 12.05 (4), Wis. Adm. Code.
Signature: Date: **Reference**
Please list three work and/or education related references. Do not list friends or relatives .
Name: Relationship: Phone: Name: Relationship: Phone: Name: Relationship: Phone: **Agreement**
I verify that all the information which I have provided on this application and in resumes/exhibits is true, correct and complete. I understand that false, misleading, incomplete or omitted information will result in rejection of my application or dismissal from employment, whenever discovered. If my application is considered for employment, I authorize an investigation and verification of all information and statements provided on this application and in resumes and exhibits. I release any and all persons or companies from any liability for releasing information or verifying statements on this application and in resumes/exhibits.
I understand that this application is not a job offer or a contract of employment for any specific time period. If hired, my employment will be for an indefinite time period and I may resign or be terminated by the facility at any time without notice or requirement of cause.
Employment is subject to completion of pre-employment procedure, including but not limited to verifying employment personal references, criminal record and driving record (where appropriate), and confirmation of professional licensure or registration. Applicants hired must complete a federal I-9 form and provide verifying documentation of their legal right to reside and work in the United States.
Applicants extended a conditional job offer may be asked to submit to a medical exam by a medical practitioner selected by the facility. The exam results will be communicated to the facility and used to determine suitability for employment. In conducting the medical exam, the facility will reasonably accommodate the disabilities and handicaps of qualified applicants in compliance with applicable law. Applicants who refuse to submit to a medical examination will not be further considered for employment.
I further agree that if employed, I will comply with all policies, rules and procedures of the facility. I further give consent for the facility for which I am applying to contact former employers to obtain references and verify information as needed.
By signing and dating this form, I hereby swear all the above information is correct.
**My typed first and last names below shall have the same force and effect as my written signature.**
Signature: Date: