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Preliminary Application

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, or any other characteristics protected by law.

Passing a drug test is required as a condition of employment.

APPLICANTS INTERVIEWED FOR A POSITION WILL BE ASKED TO COMPLETE A MORE THOROUGH APPLICATION.

Position applying for:
Date:
Date available to work:
E-Mail:
First Name:
Middle Initial:
Last Name:
Street Address:
City:
State:
Zip Code:
Telephone:
Day-Time Telephone:
I wish to be considered for:
Full-time Part-time Temporary
1st Shift 2nd Shift 3rd Shift
Any days or times unavailable
for work?
(Please Explain)

CURRENT AND PREVIOUS EMPLOYER(S)

EMPLOYER:

DATES EMPLOYED:

JOB TITLE(S):

EMPLOYER:

DATES EMPLOYED:

JOB TITLE(S):

EMPLOYER:

DATES EMPLOYED:

JOB TITLE(S):

EDUCATION/MILITARY SERVICE: Please check applicable information.

High School Diploma            GED           Military Service
College Degree          Major:

Are you at least 18 years old?
 Yes No
Do you have a valid Wisconsin driver's license? Yes No
Have you been convicted of any crime, including a misdemeanor or a felony conviction?  Do you have any criminal charges pending at this time?
Yes
 No
A CONVICTION DOES NOT AUTOMATICALLY BAR YOU FROM EMPLOYMENT. HOWEVER FALSIFICATION OF YOUR APPLICATION IS CONSIDERED REASON TO PREVENT OR TERMINATE YOUR EMPLOYMENT.

Other Job Related Skills:
(Please Explain)

Invitation to Identify for Affirmative Action Purposes
Our organization is an equal opportunity/affirmative action employer and does not discriminate in hiring or employment on the basis of race, creed, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual preference or any other status prohibited by federal, state or local law. No question on this form is intended to secure information to be used for such discrimination.

Our organization is required by federal regulations to report information as requested below. Your disclosure of this information is completely voluntary. The information you elect to provide is confidential and will be maintained separate from your personnel file.
Male Female
REFERRAL SOURCE
Advertisement (Source )
Employee Referral (Name of person who referred you )
Employment/Temp Agency Government Agency
School/College State Job Service Walk-In
PLEASE INDICATE THE APPROPRIATE RACE/ETHNIC GROUP
White (Not of Hispanic Origin)
Black/African American (Not of Hispanic Origin)
Hispanic
Asian/Pacific Islander
American Indian/Alaskan Native
Government Contractors/Subcontractors subject to the Vietnam Era Veterans Readjustment Act of 1974 and the Rehabilitation Act of 1973 are required to take affirmative action to employ and advance in employment other eligible veterans (including Vietnam Era veterans), qualified special disabled veterans and disabled individuals. Submission of this information is voluntary; refusal to provide it will not subject you to any adverse treatment. The information provided will be held in confidence, will be maintained separate from your personnel file, and will not be used in a manner inconsistent with the Acts.
PLEASE CHECK IF ANY OF THE FOLLOWING ARE APPLICABLE
Recently Separated Veteran (A veteran who has been discharged or released from active duty within the past three-year period)
Vietnam Veteran (Served between 1964-1975)
Disabled Veteran (An individual who is rated under Veterans Administration rules as having a disability of 30% or more, or a disability of 10% or 20% that qualifies as a serious employment handicap, or has been released from active duty under a service connected disability)
Disabled Individual (An individual who has a mental or physical impairment which substantially limits one or more major life activities, has a record of such impairment, or who is perceived as having such an impairment)
If you are an individual with a disability or a disabled veteran, we ask that you inform us of any reasonable accommodation(s) you feel you may need in order to perform the essential functions of the job for which you have applied.

By submitting this form I certify that the answers given by me to the foregoing questions and statements are true and correct without consequential omissions of any kind. I agree that the company shall not be held liable in any respect if my employment is terminated because of false statements, answers or omissions made by me in this application.  I understand that any misleading or incorrect statements may render this application void, and if employed, may be cause for termination. I understand that a medical examination based on the requirements of the position for which I am being considered may be required, and drug testing may be included as part of a regular pre-employment physical exam.

I also authorize the organizations, schools or persons named above to give any information requested regarding my employment, character and qualifications. I hereby release said organizations, schools or persons from all liability for any damage for issuing this information. In consideration of my employment, I agree to conform to the rules and regulations of this organization. My employment and compensation can be terminated with or without cause, and with or without notice, at any time, at the option of either my employer or myself.
     
Oconomowoc Developmental Training Center | 36100 Genesee Lake Rd. Oconomowoc, WI 53066
262-569-5515 | Fax: 262-569-6337
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