Upland Hills Health Online Job Application

Upland Hills Health fully subscribes to the principles of an Equal Opportunity Employer. Equal access to programs, services and employment is available to all persons. Those applicants requiring accommodation to the application and/or interview process should contact a representative of the Human Resource Department at (608) 930-7105.

Position(s) applied for:

Date of Application:

Referral Source:

Advertisement	Relative	Government Employment Agency
Employee	Internet	Private Employment Agency
Walk-in	Other

Name of Source (if applicable):

Name:


Last		First		Middle

Address:


Street		City


State		Zip Code

Home Telephone:

If necessary, best time to call you at home is:

Cell Phone:

If necessary, best time to call your cell phone is:

Work Phone:

May we contact you at work?

Yes

If yes, work number:

Best time to call you at work is:

Home E-Mail Address:

Work E-Mail Address:

If you are under 18, can you furnish a work permit? Yes No

Have you filed an application here before? Yes No

If yes, give date:

Have you ever been employed here before? Yes No

If yes, position:

Date Start:

Date End:

Are you legally eligible for employment in this country? Yes No

(Proof of U.S. Citizenship or immigration status will be required upon employment)

Date available for work:

Are you on lay-off and subject to recall? Yes No

Will you relocate if job requires it? Yes No

Are you able to meet the attendance requirements of the position? Yes No

Will you work overtime if required? Yes No

Have you been convicted of a felony in the last seven(7) years? Yes No

(Under the Wisconsin’s Care giver Background Law, answering “yes”
to this question does not constitute an automatic bar to employment.
Factors such as date of the offense, seriousness and nature of the violation,
rehabilitation and position applied for will be analyzed according to Wisconsin law,
and/or, if the conviction is substantially related to the requirements of the position.)

If yes, please explain:

Driver’s license number:
(if job-related)

State:

Professional License Number:
(if job-related)

State:

Employment History

List your last four (4) employers, assignments or volunteer activities, starting with the most recent.
Explain any gaps in employment in the comments section below. Note: You must complete all sections,
including addresses, telephone numbers, wages and past supervisors. Start with your present or last job.

Employer:

Address:



Street City



State Zip Code

Telephone Number:

Job Title:

Supervisor:

Reason for Leaving:

Dates Employed:

       Full-Time

From To Part-Time

Salary Information:

       (Per Hour)

Starting Wage Ending Wage

Summarize the nature of the work performed and job responsibilities:

Comments:

Skills and Qualifications - Summarize any special training, skills, licenses, certificates
and/or characteristics of yourself that may qualify you as being able to perform
job-related functions for the position which you are applying:

Educational Background

A. List last three(3)schools attended, starting with the most recent, B. List number of years completed.
C. Diploma/Degree and D. Did you graduate(yes/no).

A. School Name/Address/Telephone #	B. Years Completed	C. Degree Earned	D. Did you Graduate?
1.			Yes No
2.			Yes No
3.			Yes No

List any foreign language(s) you know and check the boxes that describe your skill level.

Language Speak Some Speak Fluently Read Write

1.

2.

US Military Service

Branch of Service:


From		To

Rank

Military Occupation:

Training/Experience:

References

List name and telephone number of two work references who are not related to you and are not previous supervisors.
If not applicable, list two school or personal references who are not related to you.

Name Telephone Years Known

1.

1.

List professional, trade, business or civic associations and any offices held.
(Exclude memberships which would reveal sex, race, religion, national origin, age, disability or other protected status.)

Organization Offices Held

List special accomplishments, publications, awards.
(exclude information which would reveal sex, race, religion, national origin, age, disability or other protected status.)

List any additional information you would like us to consider.

Why are you a good candidate for the position you are applying for?

Penalties for providing false or misleading information
It is understood and agreed upon that any misrepresentation by me on this application will be a sufficient cause for disqualification of this application and/or termination from the employer’s service if I have been employed.

Reference Check Release
I give Upland Hills Health the right to investigate all references and statements to secure additional information about my past employment, education and/or military record. I hereby release from liability of responsibility all persons, companies or corporations supplying such information to Upland Hills Health.

Employment at Will
I understand that just as I am free to resign at any time, the employer reserves the right to terminate my employment at any time, with or without cause and without prior notice. Nothing on the application is intended to create or imply a contractual relationship. I understand that no representative of the employer has the authority to make any assurances to the contrary.

I understand it is this company’s policy not to refuse to hire a qualified individual with a disability because of this person’s need for an accommodation that would be required by ADA. Upland Hills Health observes the right to hold and maintain this application at its discretion for future open positions. Future employment opportunities will require that a new application be completed by the applicant, unless otherwise indicated by Upland H ills Health personnel.

If employed by Upland Hills Health, I agree to work the hours, days and shifts as scheduled and I consent to all pre-employment Health requirements required by Upland Hills Health I also understand that any offer of employment is contingent upon Upland Hills Health obtaining satisfactory responses to references inquiries, successful completion of pre-employment health requirements, and a successful caregiver background check which includes a criminal and license check.

I have read, and agree to the above statements

I agree

I disagree

Date:

Preference Record

Primary Position Desired:

Primary Department Desired:

Type of employment desired: (Check all that apply)

Yes No N/A

Full Time

Part Time

Per Diem/PRN

Holidays

Weekends

*If limited term employment:

Length of Time:

*If part-time, describe your availability and scheduling conflicts:

I would prefer the following shifts:

Yes No Preference Listing

Days

Evenings

Nights

Combination

For Nursing Services applicants only; I would agree to work in the following areas:

Yes No With Training

Med/Surg

Nursing Home

OB

ER

Surgery

Recovery Room

ICU

Home Health

Hospice

House Supervisor

Outpatient Clinic

Cardiac Rehab

Copy the red security code into the box ->

On the next screen you have the opportunity to preview your application before submitting it.
The application will not be sent to Upland Hills Health until you
click the "Submit" button at the bottom of the preview page.

if you wish to send a resume with your completed online application form,
please send that in a separate email to the following address: marxt@uplandhillshealth.org.