Curative's Online Employment Application

		form_App_send.asp 7.20.07
	Fields marked with a carrot ( ) are required for processing, otherwise this form will not submit.
	PERSONAL DATA
	Position applied for
	Date of application
	Type of employment:	FT PT 1st shift 2nd shift
	Desired Salary Range
	Last Name
	First Name
	Middle Initial
	Have you ever applied at this company before?	No Yes If Yes, when:
	Have you ever worked at this company before?	No Yes If Yes, when:
	Address
	Street
	City
	State / Province
	Postal Code
	Telephone	(include area code)
	e-mail address
	Are you legally eligible for employment in the U.S.: Yes No
		(Proof of U.S. citizenship or immigration status will be required upon employment)
	Licenses
	WI Drivers License	(if required for the position)
	Public Passenger License No.	(if required for the position)
	Current Professional Licenses or Certifications (list all that apply) i.e. CNA, LPN, Occupational Therapy, Physical Therapy, RN, Speech Pathology
	Issuing State: Number:
	Issuing State: Number:
	Issuing State: Number:
		Have applied for State Am applying for State

	Education
	Highest grade completed:	8 9 10 11 12 13 14 15 16
	High School
	Did you graduate?	Yes No Diploma Certificate
	College
	Did you graduate?	Yes No
	Post Graduate
	Did you graduate?	Yes No
	Vocational
	Did you graduate?	Yes No
	Associations
	Membership in Professional or Civic Organizations. (Exclude those which may disclose your race, color, religion, disability, or national origin)



	Military Status
	Active Duty:	From to Branch
	Discharge:	Honorable Other
		If other please explain
	Describe any training received relevant to the position for which you are applying
	Skills and Experience
	List special skills, training, and equipment operated
	Caregiver Background Information
	Have you ever been convicted of a crime or pleaded no contest for any offense or violation other than minor traffic violations?
	No Yes	If yes, explain 1) nature of crime, 2) date of conviction, and 3) county and state in which convicted.

		(Convictions are NOT an automatic bar to employment)
	Do you have any pending criminal charges against you?
	No Yes	If yes, describe 1) nature of charges, 2) date of conviction, and 3) county and state in which convicted.


	EMPLOYMENT HISTORY
	Previous Employers: (beginning with most recent)
	Company Name:
	Address:
	Telephone:
	Name of Supervisor:
	Employed	From:
		To:
	Job title and duties:
	Salary:	Hourly Annual Salary
	Reason for leaving:
	May we contact your current employer?	Yes No
	Next Previous Employer:
	Company Name:
	Address:
	Telephone:
	Name of Supervisor:
	Employed	From:
		To:
	Job title and duties:
	Salary:	Hourly Annual Salary
	Reason for leaving:
	May we contact your past employer?	Yes No
	Next Previous Employer:
	Company Name:
	Address:
	Telephone:
	Name of Supervisor:
	Employed	From:
		To:
	Job title and duties:
	Salary:	Hourly Annual Salary
	Reason for leaving:
	May we contact your past employer?	Yes No
	PLEASE READ THIS CAREFULLY BEFORE SUBMITTING THIS FORM:
1. I certify that the information on this application is true and correct to the best of my knowledge and belief. I understand that misrepresentations or omissions of any kind may result in denial of employment or be cause for subsequent dismissal if I am hired. 2. I authorize the company to investigate my responses on this application and contact any or all of my former employers, schools or individuals familiar with me, my employment background, my character or my qualifications for the purpose of verifying any information I have provided and/or for the purpose of obtaining any information, whether favorable or unfavorable, about me or my employment. I voluntarily and knowingly fully release and hold harmless any person or organization that provides information pertaining to my employment or me. 3. I understand that Curative Care Network is required by the State of Wisconsin to conduct a criminal background check. I understand that information required to conduct the investigation will be sent to several state and out-of-state organizations including the Department of Health and Family Services, Department of Justice’s Crime Information Bureau and the National Practitioner Database if I hold a professional license; and will include an electronic search of all appropriate databases. 4. I certify that I have never been convicted of child abuse or crimes against sexual morality involving children or adults. 5. I understand that upon receiving a job offer I consent to a pre-employment physical and drug test as required by Curative and to be performed by a designate of Curative. 6. I understand that certain specific job classifications will be required to sign as a condition of employment, a “Not to Compete Agreement”, and if applicable, this will be discussed during the interview process. 7. Regardless if whether or not I become employed by the company, I recognize that this application is not and should not be considered a contract for employment. I understand that employment at the company is on at will basis and that my employment may be terminated with or without notice, at any time, at my option or the company’s, unless specifically provided otherwise in a written employment contract. I further understand that no company employee or representative has the authority to enter into a contract regarding duration or terms and conditions of employment other than an officer or official of the company, and then only by means of a signed, written document. Curative is committed to maintaining a drug free work environment in compliance with the Drug Free Workplace Act of 1988. Curative is supportive of, and obligated under, the Americans with Disabilities Act to provide reasonable accommodations for qualified job applicants and employees with disabilities. You are encouraged to request and discuss reasonable accommodations at any time during the application process, during job interviews or after employment at Curative. (You will be required to sign this document if you are asked to come in for an interview)
	Please check all information carefully before proceeding. (RETURN TO TOP)
	Submit this resume one of two ways:
	Via Internet – Click APPLY NOW button. or (you may wish to print a copy FIRST for your records)
	Via mail – printout the completed application from your browser (file / print) and mail to: Curative Care Network Human Resource Services 1000 North 92nd Street Milwaukee, WI 53226-4800