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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.

If you have any questions or concerns, please call: or email:

All required fields are marked with an asterisk(*)






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




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?


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


Date Available for Employment:




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

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.


Employers 1

Dates Employed:

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:





Acts, Crimes, and Offenses That May Act As A Bar Or Restriction


Other Required Information



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.


Reference

Please list three work and/or education related references. Do not list friends or relatives.


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.


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In addition to our clinics in Eau Claire and Chippewa Falls, we also offer outreach clinics in Amery, Baldwin, Black River Falls, Cumberland, Durand, Neillsville, Rice Lake, Shell Lake, and Stanley.


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