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Trempealeau County Health Care Center Employment Application
Trempealeau County Health Care Center believes potential employees should know the following information:
· It is the policy of the Health Care Center to provide equal employment opportunities to all persons qualified for employment and to all employees without regard to the person’s race, color, sex, creed, religion, national origin, marital status, status with regard to public assistance, disability or age, as well as equal employment opportunities to veterans and handicapped persons.
· Any offer of employment is contingent upon the applicant’s ability to provide documentation which proves his/her employment eligibility status under the Immigration and Reform Act of 1986.
· Anyone being considered for employment MUST complete and sign the application.
Applicant Information
First Name:*

Middle Initial

Last Name:*

Current Date (mm/dd/yyyy):

Referral Source:

Social Security Number:

Email Address:

Present Address:*

City:*

State:*

Zip Code:*

Primary Phone:*

Secondary Phone:

Are you eligible to work in the United States?*
Yes No 

Wisconsin CNA Registry Number (if registered):

Have you ever pleaded guilty to or been convicted of any criminal offense?*
Yes No 

Are you currently serving probation or any deferred adjucation for a criminal offense?*
Yes No 

If yes, give all relevant details concerning each conviction or pending charge. NOTE: A conviction record will not necessarily exclude you from employment. Factors such as age at time of offense, rehabilitation efforts, how recent the offense was, nature of the crime and type of job for which you are applying will be considered.

Our facilities are drug, alcohol and smoke-free workplaces. Could you comply with this regulation?*
Yes No 

Work Preference
Postion Desired:*

Date available to begin employment*

Salary Expected:

Applying for (check all that apply)
Full Time

Part Time

Days

P.M. Shift

Nights

Education
High School Name/Location:

Years Completed:

Diploma Received:
Diploma Equivalency None 

College or University Name/Location:

Years Completed:

Degree Earned:

Other

Years Completed:

Degree/Certification Earned:

Military:

Dates of Service:

Branch:

Special Skills, Training:

Employment History
Are you providing a resume? If yes, email to kclatt@tchcc.com*
Yes No 

Name Of Most Recent Employer:

Ending/Current Position:

Employer Phone:

Address:

City:

State:

Zip Code:

Employed From:

Employed To:

Starting Position:

Ending Pay (hourly):

May we contact your present employer at this time?
Yes No 

Immediate Supervisor Name:

Reason For Leaving - if discharged, please explain:

Describe your duties and responsibilities:

Name Of Previous Employer:

Ending Position:

Employer Phone:

Address:

City:

State:

Zip Code:

Employed From:

Employed From:

Starting Position:

Ending Pay (hourly):

Immediate Supervisor Name:

Reason For Leaving - if discharged, please explain:

Describe your duties and responsibilities:

Name Of Previous Employer:

Ending Position:

Employer Phone:

Address:

City:

State:

Zip Code:

Employed To:

Employed From:

Starting Position:

Ending Pay (hourly):

Immediate Supervisor Name:

Reason For Leaving - if discharged, please explain:

Describe your duties and responsibilities:

Skills Section
Please outline any experience you have in any facet of the health care industry that is not addressed in the employment history.

Does this application adequately reflect the scope of your professional experience? If not, please use the following space or email an attachment to kclatt@tchcc.com make this application complete.

Do you know of any reason you cannot perform the essential functions of the job for which you are applying, with or without reasonable accommodation?
Yes No 

Please describe any accommodation required:

Certification of Applicant
I certify that, to the best of my knowledge and belief, the statements given truly represent my background and experience. I understand that any incomplete, misleading or incorrect statements may render this application void. If I am employed and it is subsequently discovered that any answer given by me is incomplete, misleading or incorrect, my employment with the Trempealeau County Health Care Center may be terminated. I understand that employment with Trempealeau County Health Care Center is at-will and I agree that Trempealeau County Health Care Center shall not be held liable in any respect if my employment is terminated because of false, incomplete or misleading statements, answers or omissions made by me in this application.

In addition, I give the following Authorization to Release Information. I also authorize pertinent former employers, companies, schools, agencies, municipalities or persons to give to Trempealeau County Health Care Center any information requested regarding my employment, character, experience and qualifications, and/or suitability for employment with the County, including a background for purposes of considering my suitability for hire. I hereby forever release, discharge and covenant not to sue any person or organization for any result of providing, obtaining or acting upon such information. I understand that such information is sought with confidentiality and will not be released to me in any form whatsoever.

I understand that my name and other pertinent information may be released to the general public and to the news media if this information is requested according to the requirements stated in Wisconsin’s Open Records Law. Skill and drug testing may be required depending upon the position for which you are applying. In addition, a copy of this authorization is as valid as the original and should be recognized as such. Finally, I have read and understand the description of the job I am applying for and I certify that I am able to perform all the required functions of the job.

Applications more than six months old may not be considered for current openings.
Signature (please type your name):*

Date (mm/dd/yyyy):*

Applicant Data Survey
Trempealeau County Health Care Center is committed to non-discrimination in employment.
To assist in this effort, we ask your voluntary cooperation in responding to the questions below.

The data collected will be used for statistical and affirmative action purposes only.
Responses will not be used in evaluating your application.
Position Applying for:
CNA

PCW

RN/LPN

Food Service

Other:

Do you wish to provide the following information?
Yes No 

I am:
Male Female 

Are you Hispanic or Latino (A person of Mexico, Puerto Rico, Cuban, Central or South American, or other Spanish culture or origin unique to the Americas, regardless of race)?
Yes No 

Race (not Hispanic or Latino):
African American/Black: A person having origins in any of the black racial groups of Africa.

American Indian/Alaska Native: A person having origins in the original peoples of North America who maintain cultural identification through tribal affiliation or community recognition.

Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent, including, for example, Cambodia, China, India, Philippine Islands, and Vietnam.

Native Hawaiian or Other Pacific Islander: A person having origins in any of peoples of Hawaii, Guam, Samoa or other Pacific Islands.

White/Caucasian: A person having origins in any of the original peoples of Europe, North Africa, the Middle East, or Southwest Asia.

A person who identifies with more than one of the five faces listed above. If you select this option, please indicate a primary race:


Primary Race:

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