As an Equal Opportunity Employer, Columbia Center (here and after referred to as "The Organization") does not discriminate against qualified applicants in hiring or in promoting qualified employees because of age, race, creed, color, religion, marital status, sex, national origin, ancestry, citizenship, sexual orientation, handicap, disability, arrest and/or conviction record, membership in the National Guard or any other reserve component of the military forces of the United States or Wisconsin, or other protected status, as required by law.

* required information (Please enter "NA" if there is no information.)

Personal Information

First Name: *

Middle Initial:

Last Name: *

Address: *

City: *

State: * -- Select --AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip: *

Last 4 Digits of Social Security Number: *

Home Telephone: *

Work Telephone:

Email Address: *

Position Interested In: * Please Select One Other - Please specify

Best time of day to reach you by phone at home: *

Best time of day to reach you by phone at work:

Additional Information

Wage Desired:

When will you be available to begin work? *

How were you referred to us? * Please Select One Advance Magazine Americasjobbank.com Columbia Center website Employee referral Employment Times Facebook Job Fair Job line JobNoggin.com Lakeshore Newspapers Milwaukee Journal/Sentinel Milwaukeejobs.com NursingJobs.org OZ/WAS Guide Ozaukee Press Promotion Rehire Self referral Sheboygan Press Twitter Wijobs.com Yahoo Other website Other

If you were referred by a current employee, enter their full name and department:

Are you seeking work for? * Please Select One Full Time Part Time Full Time or Part Time Pool

How many hours/week?

Which shifts would you consider?
(Rotation may be required on any shift.) * First
Second
Third

Are you available to work weekends?
(Rotation may be required.) * Yes No

Are you available to work holidays?
(Rotation may be required.) * Yes No

Please answer all of the following questions.

Have you ever worked at Columbia Center? * Yes No
List (Include dates and positions held.)

Have you applied here within the last six months? If "yes", when, where and what position? * Yes No

Are you either a U.S. Citizen or do you otherwise have legal authorization to work in the United States which is not limited to a particular employer? *Yes No

Are you 18 years or older? *Yes No

Have your employment or education records ever been listed under another name? If "yes," please indicate name(s) and dates: *Yes No

Work History

Complete telephone and address information is required.

Please enter "NA" if there is no information. Begin with your present or most recent employer.

1. Most recent employer

Name of Employer: *

Street Address: *

City, State, Zip: *

Area Code & Phone Number: *

From: *

To: *

Hourly Rate/Salary: *

Supervisor's Name: *

Your job title and clinical area, if applicable: *

Reason for leaving: *

May be contacted for a reference? * Yes No

2. Second employer

Name of Employer:

Street Address:

City, State, Zip:

Area Code & Phone Number:

From:

To:

Hourly Rate/Salary:

Supervisor's Name:

Your job title and clinical area, if applicable:

Reason for leaving:

May be contacted for a reference? Yes No

3. Third employer

Name of Employer:

Street Address:

City, State, Zip:

Area Code & Phone Number:

From:

To:

Hourly Rate/Salary:

Supervisor's Name:

Your job title and clinical area, if applicable:

Reason for leaving:

May be contacted for a reference? Yes No

Where there any periods of time when you were not in school or working? *Yes No

Dates:

Reasons:

Have you ever been fired, discharged or asked to resign? *Yes No

If "yes," please explain:

Resume

To cut and paste your resume:

1. Highlight the text on the resume you want to copy.
2. Press "Ctrl C" to copy. (Hold down the "Control/Ctrl" key and press the "C" key.)
3. Place the cursor in the "Resume" box below.
4. Press "Ctrl V" to paste the information.

Cover Letter

Resume

Educational History

(All information is required. Please enter "NA" if there is no information.)

Professional Licensure

Specialized Skills

PC/Software Skills i.e. Word, Excel, PowerPoint, Envision, Access, MS4, etc.

Word Processing Which systems?

Data Entry (KPH)

Medical Terminology

Other

Criminal Background Check

LIST ALL CONVICTIONS.
(This would include felony, misdemeanor or municipal ordinance(s) including any time you have paid a fine.)
Do not include minor traffic violations. If None or Not Applicable, please put NA. *

List all pending criminal charges. If None or Not Applicable, please put NA. *

No applicant will be denied a position because of a pending criminal charge or conviction for (or plea of nolo contendere or no contest to) an offense or violation (whether criminal or otherwise) which The Organization determines is not substantially related to the circumstances of the job. I understand that any false or misleading information that I provide to The Organization as part of this conviction information statement, or the withholding of information deemed pertinent by The Organization, will result in dismissal and rejection of me as an applicant or termination of my employment.

Signature: *

Date: *

Additional Information

Are there any other pertinent facts that you would like to tell us which, in your opinion, may help us evaluate your qualifications for the position you are seeking? If so, please list the facts below:

In addition to English, do you speak any other languages?List languages

Does your current supervisor know you are applying for this position? Yes No

Certificate Reference/Release Authorization

• I certify that the information given herein and any resume or other information I provide to The Organization as part of the hiring process is complete and accurate to the best of my knowledge. In the event of employment, I understand that any false or misleading information given in my application, resume or any other information I provide to The Organization as part of the hiring process or the withholding of information deemed pertinent by The Organization will result in dismissal and rejection of me as an applicant or termination of my employment. Upon my termination, I authorize the release of reference information on my work.
• I also grant permission for the authorities of The Organization to investigate my criminal / civil / ordinance history record, employment references, credentials, qualifications, and any statement I have made in this application, resume or during the hiring process and release The Organization and all previous employers, schools, and organizations I have identified (and all persons connected with it or them) from any and all liability resulting from such investigation.
• I understand that if offered a position, I grant permission to The Organization to obtain a copy of my State Motor Vehicle Driving Record and verification of auto insurance, if applicable. I have been informed that I will need to provide The Organization with my Driver's License Number in order to obtain the State Motor Vehicle Driving Record.
• I understand and agree that, if employed by The Organization, this employment is not for any definite period or succession of periods, and that it may be terminated either by myself or by The Organization at any time without notice, and wages shall be due only up to the effective day and hour of termination of employment. I understand the only person who has the authority to enter into employment with me for a definite period of time on behalf of The Organization is an officer of the corporation. This can only be done so with written agreement signed by an officer of the corporation.
• I consent to any and all medical examinations and drug screens required by The Organization. I understand that the successful completion of a medical examination including a drug screen is required of all applicants who are offered positions at The Organization as a condition of employment.
• I understand that if offered a position I must present proof of my identity and employment eligibility in order to be employed, as required by law.
• I am aware that The Organization has a restricted smoking policy and that I will be required to comply with this policy.
• The Organization operates 24 hours per day, 7 days a week and has two departments. I understand that it may be necessary for me to work weekends and/or holidays, overtime, different shifts, or in either department. Locations may vary and can be unpredictable.
• I understand that as part of my application to The Organization noted on page 1 of the application, information that is obtained as part of this application and process may be disseminated as appropriate to other Columbia Center related entities.
• As part of the background check process, Columbia Center is required to query the Office of the Inspector General and the General Services Administration for all individuals that we employ or contract with. These entities make a list of "excluded providers," who for various reasons have been excluded from federally funded programs. The federal government mandates Columbia Center to review these excluded provider lists and based on information received, Columbia Center may need to rescind an offer of employment.
• I consent to any and all skills, knowledge and ability employment tests for the position(s) for which I am applying. I understand that any employment test is deemed relevant to the job responsibilities of the position, by the organization and that the successful completion of such tests is necessary for employment.

My typed name below shall have the same force and effect as my written signature.

Candidate's/Applicant's Signature: *

Date: *

 * Required