Job Application

Thank you for your interest in working for OakLeaf Clinics We look forward to receiving your application.
For timely processing of your application, please follow all instructions carefully and ensure you complete step five.

All required fields are marked with an asterisk(*)

Preferred Position:

If the position for which you are applying is not available, are you willing to be considered for a similar position at another OakLeaf Clinic facility?

Yes No

Name: *

Primary Phone: *

Secondary Phone:

Address: *

City: *

State: *

Zip: *

Email: *

Where did you hear about this position?

Have you ever worked at any OakLeaf Clinic location?

Yes No

If yes, which location have you worked at:

Have you ever applied at any OakLeaf Clinic location?

Yes No

If yes, which location have you applied at:

Conviction of a crime is not an automatic bar to consideration for employment.

Have you ever pleaded guilty to or been convicted of any criminal offense, excluding minor traffic citations? *

Yes No

Are you currently serving probation or any deferred adjudication for a criminal offense? *

Yes No

Our facilities are drug, alcohol, and smoke free workplaces. Could you comply with this regulation? *

Yes No

Are you a veteran? *

Yes No

Please list, in order of preference, the position(s) for which you wish to be considered:

List any additional trades or qualifications you may have for the position you have applied for:

If the position you are applying for requires certification or licensing, when does the certification or licenses expire and in what state is it issued?

Expires:

State:

How experienced are you in the position you have requested? Experience in years/months:

Years:

Months:

Date Available for Employment:

Date:

Number of desired hours per week:

Cover Letter:

Resume: *

Do you have a high school diploma or GED?

Yes No

High School/GED City:

In the spaces below, please list any additional schools beyond High School/GED that you have attended, number of years completed, degrees received, and your primary area of study

Post Secondary 1

School/City/State:

Years Completed:

Estimated Completion:

Add

Work History

Please provide your employment data for the last seven years. List your current or most recent position first. Explain all periods of unemployment. References will be required before employment.

May we contact your present employer at this time?

Yes No

Have you ever been discharged or requested to resign?

Yes No

Employers 1

Employer:

Supervisor Name:

Phone:

Address, City, State, Zip:

Starting Hourly Rate:

Ending Hourly Rate:

Dates Employed:

Start Date: (Month, YYYY):

End Date (Month, YYYY):

I still work here

Position(s) held and major job duties:

Reason for leaving:

Add

Background Information Disclosure

For instructions, see F - 82064A. 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 Appendix, F - 82069, 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 (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

Do you have any criminal charges pending against you or were you ever convicted of any crime anywhere, including in federal, state, local, military and tribal courts?

Yes No

Were you ever found to be (adjudicated) delinquent by a court of law on or after your 10th birthday for a crime or offense? 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

Has any government/regulatory agency (other than the police) ever found that you committed child abuse or neglect?

Yes No

Has any government/regulatory agency (other than the police) ever found that you abused or neglected any person or client?

Yes No

Has any government/regulatory agency (other than the police) ever found that you misappropriated (improperly took or used) the property of a person or client?

Yes No

Has any government/regulatory agency (other than the police) ever found that you abused an elderly person?

Yes No

Do you have a government issued credential that is not current or is limited so as to restrict you from providing care to clients?

Yes No

Other Required Information

Has any government/regulatory agency ever limited, denied, or revoked your license, certification, or registration to provide care, treatment, or educational services?

Yes No

Has any government/regulatory agency ever denied you permission or restricted your ability to live on the premises of a care providing facility?

Yes No

Have you been discharged from a branch of the US Armed Forces, including any reserve component?

Yes No

Have you resided outside of Wisconsin in the last three years?

Yes No

Have you had a caregiver background check done within the last four years?

Yes No

Have you ever requested a with the Wisconsin Department of Health Services, a county department, a private child placing agency, school board, or DHS design?

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:

Email:

Name:

Relationship:

Email:

Name:

Relationship:

Email:

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: