Human Resources Department APPLICATION. Employee Student Volunteer Other:

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1 Human Resources Department Valley Road Oconomowoc, WI Toll-free Fax no.: West Lincoln Ave Milwaukee, WI Toll-free Fax No.: th Street Kenosha, WI Toll-free Fax No.: Schroeder Drive Brown Deer, WI Toll-free Fax No.: APPLICATION Employee Student Volunteer Other: It is the policy of this hospital to extend its employment opportunities to qualified persons on a nondiscriminatory basis. Selection shall be made without regard to age, race, color, sex, national origin, disability, or any other class protected by law. Rogers Memorial Hospital is a Smoke Free Environment NAME (please print): DATE: REFERRAL SOURCE: POSITION(s) DESIRED*: *You must indicate a specific position in order to be considered for employment. CAMPUS PREFERENCE: Milwaukee Oconomowoc Kenosha Brown Deer PLEASE CHECK ALL BOXES THAT APPLY. STATUS: Regular Full Time Regular Part Time Shift Preference 1st 2nd 3rd Temporary Will Help on PMs and Night Shifts yes no Pool Will Work Alternate Weekends/Holidays yes no some DATE AVAILABLE TO START: SALARY EXPECTED: Page 1 of 11

2 This page must be signed in acknowledgement before any action will be taken by Rogers Memorial Hospital for employment consideration. If you have any questions regarding this application process please contact the Human Resources Department. PLEASE READ BEFORE SIGNING: o I hereby certify that all of the information provided by me on this application (or any other accompanying or required documentation) is true and complete. I understand that the falsification, misrepresentation or omission of any facts in said documents will be cause for denial of employment, consideration of employment, and/or immediate termination of employment regardless of the timing or circumstances of the discovery. I agree that Rogers Memorial Hospital, Inc. shall not be held liable in any respect if I am denied employment or my employment is terminated because of false statements, answers or omissions made by me on this application for employment or any other document. I further understand that any falsification and/or omission of information on said documents serve as a permanent bar of employment and/or consideration for employment. o It is the policy of Rogers Memorial Hospital, Inc. to afford equal opportunity to all employees and applicants for employment without regard to age, race, religion, color, gender, national origin, marital status, expunged juvenile records or pregnancy and to afford equal opportunities to disabled veterans, veterans of the Vietnam era and individuals with a disability and any other characteristics protected by federal, state or local law. o I understand that submission of an application does not guarantee employment. I further understand should an offer of employment be extended by Rogers Memorial Hospital, Inc. that such employment with Rogers Memorial Hospital, Inc. is At Will, for no specified duration and may be terminated by either Rogers Memorial Hospital, Inc. or myself at any time, with or without cause or notice. I understand that none of the documents, policies, procedures, actions or statements of Rogers Memorial Hospital, Inc. or its representatives used during the employment and/or application process is deemed a contract of employment, real or implied. I understand that no representative of Rogers Memorial Hospital, Inc. except the Hospital President/CEO has the authority to enter into any agreement guaranteeing any conditions of employment or any agreement contrary to the foregoing statements and that any such agreements must be made in writing and signed by the Hospital President/CEO. o I understand that if offered a position for employment with Rogers Memorial Hospital, Inc. I may be required to submit to a post-offer medical examination, drug screening and/or background check as a condition of employment. I understand that unsatisfactory result from, refusal to cooperate with or any attempt to affect the results of these pre-employment and/or post-offer tests, checks, and verifications will result in withdrawal of any employment offer or termination of employment if already employed by Rogers Memorial Hospital, Inc...continued on next page Page 2 of 11

3 o I understand that this application is considered current for thirty (30) days. If I wish to be considered for employment after this period, I must fill out and submit a new application. Additionally, I understand that I must specify the position(s) I am applying for the purpose of this application. Failure to specify will result in my application not being considered for employment for any position. o I authorize any and all schools, former employers, references, courts, and any others who have information about me to provide such information to Rogers Memorial Hospital, Inc. and/or any of its representatives, agents or vendors. I understand that the information may include but is not limited to performance evaluations and reports, job descriptions, disciplinary reports, letters of reprimand, and opinions regarding my suitability for employment possessed by it. o I fully release and discharge, absolve, indemnify and hold harmless all parties involved in this process from any and all claims, liability, demands, causes of action, damages or costs including attorney fees, present and/or future, whether known or unknown, anticipated or unanticipated, arising from or incident to the disclosure or release except for the malicious and willful disclosure of derogatory information concerning my employment made for the express purpose of preventing me from obtaining employment which the party disclosing such facts knows are untrue. o I understand that Rogers Memorial Hospital, Inc. operates 24 hours per day, 7 days per week, and that weekend work or changes of shift may be required if I am employed. o I acknowledge that I have read and understand the above statements and hereby grant permission to confirm the information supplied by me on this application and any other accompanying or required documents. DATE: APPLICANT S SIGNATURE: Page 3 of 11

4 GENERAL INFORMATION: Name: Social Security Number: Last First Initial Address: Street City State Zip Code Telephone Number: ( ) Are you: Under or Older Are you known to schools/references by another name? Yes No If yes, name: Are you authorized to work in the United States? Yes No Have you ever been employed here before? Yes No If yes, when? Title of Position: Are you acquainted with anyone who is or has been employed here? Yes No If yes, name: Position: Still employed: Have you ever been convicted and/or cited for any offense or violation other than minor traffic violations? Yes No If yes, explain 1) nature of crime, 2) date of conviction, and 3) state in which convicted. (Convictions are not an automatic bar to employment. Lack of disclosure may do so.) Do you have any pending criminal charges against you? Yes No If yes, describe the 1) nature of the charges, 2) date issued, and 3) county and state where issued. Are you on layoff subject to recall? Yes No Are you able, with or without accommodation, to perform the essential functions of the job for which you have applied? Yes No Do you SPEAK, READ, or WRITE another language? (circle all that apply) Yes No Which language? In the past three years, have you ever knowingly used any drugs (amphetamines, barbiturates, benzodiazepines, cannabinoids, or opiates) other than those prescribed to you by a physician? Yes No If yes, please furnish details: EDUCATION: Name and Address of School Course of Study Last Year Completed High College Graduate Other (specify) Diploma or Degree yes no Type: yes no Type: yes no Type: yes no Type: Page 4 of 11

5 PROFESSIONAL TRAINING: Where did you receive your professional training? Dates (from/to) Registry, Licensure or Certification No. Place of Registration EMPLOYMENT HISTORY: Please supply at least 5 years of employment history. Please begin with your present or most recent employer. 1 Present or Last Employer Immediate Supervisor Address Full Time Part Time Pool From (Mo.-Yr,) To (Mo.-Yr.) Dates Employed: Starting Salary Final Salary Your title and description of duties: Reason for considering change: Phone 2 Present or Last Employer Immediate Supervisor Address Phone Full Time Part Time Pool From (Mo.-Yr,) To (Mo.-Yr.) Dates Employed: Starting Salary Final Salary Your title and description of duties: Reason for considering change: 3 Present or Last Employer Immediate Supervisor Address Phone Full Time Part Time Pool From (Mo.-Yr.,) To (Mo.-Yr.) Dates Employed: Starting Salary Final Salary Your title and description of duties: Reason for considering change: May we contact your present employer? yes no Account for periods of unemployment other than when you were in school: PLEASE READ BEFORE SIGNING: I certify that all the foregoing statements are true and complete. I understand that any misstatement or omission of fact on this application form &/or related documents shall be sufficient cause for denial of employment or summary dismissal at any time during my employment. I consent to investigation by Rogers Memorial Hospital, Inc., of all references and previous employers to secure additional information. I release from any and all liability all representatives of Rogers Memorial Hospital, Inc., for their acts performed in good faith in connection with evaluating my application, credentials and qualifications. I understand that my application will remain active for 30 days. I understand that Rogers Memorial Hospital, Inc., operates 24 hours per day, 7 days per week, and that weekend work or changes of shift may be required if I am employed. I understand that any offer of employment is contingent upon the satisfactory completion of a physical examination and investigation of my work record and references. I understand that if I am employed by the Hospital, my employment can be terminated by either the Hospital or myself at-will, with or without cause, and with or without notice, at any time. DATE: APPLICANT S SIGNATURE: Page 5 of 11

6 EMPLOYMENT HISTORY: Please supply at least 5 years of employment history. Please begin with your present or most recent employer. 4 Present or Last Employer Immediate Supervisor Address Full Time Part Time Pool From (Mo.-Yr,) To (Mo.-Yr.) Dates Employed: Starting Salary Final Salary Your title and description of duties: Reason for considering change: Phone 5 Present or Last Employer Immediate Supervisor Address Phone Full Time Part Time Pool From (Mo.-Yr,) To (Mo.-Yr.) Dates Employed: Starting Salary Final Salary Your title and description of duties: Reason for considering change: 6 Present or Last Employer Immediate Supervisor Address Phone Full Time Part Time Pool From (Mo.-Yr.,) To (Mo.-Yr.) Dates Employed: Starting Salary Final Salary Your title and description of duties: Reason for considering change: May we contact your present employer? yes no Account for periods of unemployment other than when you were in school: PLEASE READ BEFORE SIGNING: I certify that all the foregoing statements are true and complete. I understand that any misstatement or omission of fact on this application form &/or related documents shall be sufficient cause for denial of employment or summary dismissal at any time during my employment. I consent to investigation by Rogers Memorial Hospital, Inc., of all references and previous employers to secure additional information. I release from any and all liability all representatives of Rogers Memorial Hospital, Inc., for their acts performed in good faith in connection with evaluating my application, credentials and qualifications. I understand that my application will remain active for 30 days. I understand that Rogers Memorial Hospital, Inc., operates 24 hours per day, 7 days per week, and that weekend work or changes of shift may be required if I am employed. I understand that any offer of employment is contingent upon the satisfactory completion of a physical examination and investigation of my work record and references. I understand that if I am employed by the Hospital, my employment can be terminated by either the Hospital or myself at-will, with or without cause, and with or without notice, at any time. DATE: APPLICANT S SIGNATURE: Page 6 of 11

7 34700 Valley Road Oconomowoc, Wisconsin REFERENCES References may NOT be related to you (the applicant) Please be courteous to your references and let them know we may be calling. Thank you! Personal: Please list two (2) personal references that can be contacted regarding your character. 1. Name: Phone No.: How do you know this individual? How many years have you known this individual? years. 2. Name: Phone No.: How do you know this individual? How many years have you known this individual? years. Professional: Please list past supervisors, co-workers or educators that you work with or have worked with who could be contacted regarding your work performance. 1. Name & Job Title: Employer: Phone No.: Best time to be reached: 2. Name & Job Title: Employer: Phone No.: Best time to be reached: Page 7 of 11

8 34700 Valley Road Oconomowoc, Wisconsin PERMISSION FOR REFERENCE RELEASE Please be advised that I am making application for employment with Rogers Memorial Hospital. As part of my application, I authorize Rogers Memorial Hospital to request education, personal and employment references. I also release from any and all liability all individuals and organizations who provide information to the hospital in good faith concerning my employment competence, ethics, character and other qualifications, including otherwise privileged or confidential information. Date: Signed: PERMISSION FOR ACADEMIC VERIFICATION RELEASE As part of my application, I authorize Rogers Memorial Hospital to request educational references. Education: Indicate undergraduate (U); graduate (G); and postgraduate (P) beginning with the most recent. SCHOOL ADDRESS REGISTRAR S PHONE NUMBER MAJOR DEGREE For Human Resources Use Only Degree Verification Date completed: Type of Degree: Init: Date completed: Type of Degree: Init: Date completed: Type of Degree: Init: Date completed: Type of Degree: Init: I hereby accept responsibility for any/all fees associated with the cost of source verification of degrees, education, license or certification Social Security Number: Date: Signed: Page 8 of 11

9 34700 Valley Road Oconomowoc, Wisconsin INVITATION TO IDENTIFY FOR AFFIRMATIVE ACTION PURPOSES Qualified applicants are considered for employment, and employees are treated during employment, without regard to race, color, creed, sex, national origin, age, marital status, ancestry, sexual orientation, arrest or conviction record, veteran rights, medical condition or disability, as required by law. To help us comply with state and federal equal employment opportunity record-keeping, reporting and other legal requirements, please answer the questions below. Completion of this form is voluntary and in no way affects the decision regarding your employment opportunity. The information provided will be held in strict confidence, will be maintained in a separate file, and will not be used in a manner inconsistent with State and Federal laws. Date: Position(s) Applied for: Name: Phone No.: Address: Street City State Zip Code Birth Date: Age: Sex: Male Female Marital Status: Single Married Separated Divorced Race/Ethnic Group: White Black Hispanic American Indian Alaskan Indian If accommodation is necessary in order for you to successfully perform the job, please describe: Military: Present Selective Service Status Military Duty Previous Service: Branch From To Rank Experience How were your referred to this job? Advertisement Employee Referral Employment Agency Government Agency Recruiter School/College State Job Service Walk In Other (Please Specify): Page 9 of 11

10 34700 Valley Road Oconomowoc, Wisconsin WISCONSIN CAREGIVER MISCONDUCT REGISTRY QUESTIONNAIRE Wisconsin Administrative Code HFS 12.10(1) (b) prohibits any entity regulated by the Department of Health and Family Services from: a) Hiring, employing or contracting with a person with a finding (of misconduct) placed on the registry who is expected to have access to its clients; or b) Permit to reside at the entity, a person with a finding (of misconduct) placed on the registry who is not a client, but who is expected to have access to the entity s clients. However, if the individual has received approval from a rehabilitation review authority specified in HFS 12.12, Wis.Admin.Code, these conditions do not apply. (These questions do not refer to having licensure, but rather any reported MISCONDUCT) 1. Have you ever been listed on the Wisconsin Caregiver Registry?... No Yes 2. Have you ever been listed on any state s Caregiver Registry?... No Yes 3. Have you received approval from a rehabilitation review authority?... No Yes Signature Date Page 10 of 11

11 34700 Valley Road Oconomowoc, Wisconsin CRIMINAL BACKGROUND CHECK AUTHORIZATION This form serves as an acknowledgement and authorization for Rogers Memorial Hospital to conduct a criminal background check. For this purpose, we ask that you provide the following information: Applicant s Name (please print) Any other name(s) by which you have been known (including maiden name) (please print) Drivers License Number I certify that all the foregoing statements are true and complete. I understand that any mis-statement or omission of fact shall be sufficient cause for denial of employment or summary dismissal at any time during my employment. I consent for Rogers Memorial Hospital to conduct a criminal background check. Applicant s Signature Date Page 11 of 11

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