Our mission is to support individuals to live their
best life in their own home and in their community.

Application for Employment

Desired Position *

Have you previously been employed by CLC? *

YesNo How did you hear about CLC? *First Name *Middle InitialLast Name *

Address Street *PO Box/Apt NumberCity *State *Zip Code *

Mobile Phone *Home PhoneEmail Address *

Are you age 18 or over? *

YesNoOther names used in the past three years

Driver's License

Do you possess a valid WI Driver's License? *

YesNo

Driver's license numberExpiration date

Are you licensed in another state?

YesNo

StateDriver's license numberExpiration date

Date Available for Work *

Seeking *

Part TimeFull Time

Availability *

EveningsOvernightsWeekendsDays

Education Summary

High School Name *Address *

Last year completed *

9101112

High school diploma or equivalent *

YesNo

College NameAddress

Last year completed

12345Other

Graduated

YesNo

Other NameAddressCourse of studyDiploma or degree received and date received

Please list any other certifications or training you feel would be relevant

Are you legally authorized to work in the United States? *

YesNo

Work Experience (Most recent/current employer first. List all information)

Employer 1 EmployerAddressCityStateZipPhoneDates of employmentJob TitleSupervisorEnding wageHours per weekReason for leaving

May we contact

YesNo

Employer 2 EmployerAddressCityStateZipPhoneDates of employmentJob TitleSupervisorEnding wageHours per weekReason for leaving

May we contact

YesNo

Employer 3 EmployerAddressCityStateZipPhoneDates of employmentJob TitleSupervisorEnding wageHours per weekReason for leaving

May we contact

YesNo

+ Click to add additional work experience

Are you related to anyone supported by CLC? *

YesNo

Are you related to anyone who works for CLC? *

YesNo

Can you perform the essential functions of the position for which you are applying? *

YesNo

Employment References *

Yes, I authorize CLC to investigate statements contained in this application, or an interview, and the references that I have indicated that you may contact, to give you any and all information concerning my previous employment. I release from all liability, or legal claims, every person seeking or providing information, whether oral or writtenYes, I understand that Dane County Human Services requires CLC to complete and submit information regarding my employment upon the termination of employment. This information will be provided to any prospective employers who request the information, and that CLC must provide my name, date of birth, and dates of employment to DCHS

Criminal Record and Driving Verification *

Have you ever been convicted of an offense (misdemeanor or felony)? *

YesNoYes, I understand a conviction record does not automatically disqualify an individual from consideration for employment. Conviction record will only be considered to the extent it substantially relates to the circumstances of the position applied for.Yes, I consent to CLC obtaining a copy of my driving record or other related information. I understand my driving record and personal insurance will be reviewed to ensure they meet the standards of CLC and/or liability insurance. If they do not meet the standards, I will not be able to drive my personal vehicle for work purposes.

Application Authorization and Release *

I, * * , understand this application may not be processed if any areas are left blank.

Yes, I certify that the facts set forth in my application for employment are true, correct and complete. I Understand, that if employed, any false statements, misrepresentations, or material omissions on the application may be considered grounds for immediate discharge.Yes, I certify I have read (or had read to me) and understand this authorization, release, and certification.

Attachments

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Our mission is to support individuals to live their best life in their own home and in their community.

Application for Employment

Education Summary

Work Experience (Most recent/current employer first. List all information)

Employment References *

Criminal Record and Driving Verification *

Application Authorization and Release *

Attachments

Our mission is to support individuals to live their
best life in their own home and in their community.