Butler WI Employment Application

12621 W HAMPTON AVENUE

BUTLER, WI 53007-1791

APPLICATION FOR EMPLOYMENT

In compliance with Federal and State equal opportunity laws, qualified applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, marital status, or the presence of a non-job-related medical condition or handicap.

Application Date

Month Day Year

Position(s) Applied For

If Other, please include the name of the position here

Referral Source

If Other, please include the name of that source here

Applicant's Name

First Name Middle Name Last Name

Social Security Number

Applicants Address

Street Address

Street Address Line 2

City State

Zip Code

Applicants Phone Number

Please enter a valid phone number.

Applicants Email

example@example.com

How long at present address?

Driver’s License Number

Are you a Citizen of the United States? *

Yes No

If not, do you possess an Alien Registration Card?

Yes No Not applicable

Applicants Date of Birth

Date

Have you been convicted of a felony or released from prison within the last 7 years?

Yes No

If yes, describe in full, including date(s)

In case of accident or emergency, please notify

Emergency Contact Name

First Name Middle Initial Last Name

Emergency Contact Phone Number

Please enter a valid phone number.

Emergency Contact Address

Street Address

Street Address Line 2

City State

Zip Code

Do you have a disability, a handicap or a medical condition that limits your job performance?

Yes No

If yes, please explain

Are you a veteran?

Yes No

If yes, what was your branch of Military Service and Rank?

List Trade or Professional Organizations of which you are a member, including offices held.

References: Provide the name, address and phone number of three (3) references not related to you

If References are included in your resume, please select the "See Resume" button.

Education

If Education is included in your resume, please select the "See Resume" button.

	Vocational / College	Graduate / Professional
School Name
Years Completed
Diploma Earned
Course of Study / Major

Describe specialized training, apprenticeship, skills, and extra-curriculum activities:

Employment Experience

List each job held. Start with your present or last job. Include military service assignments and volunteer activities.

Include the complete company address including city and zip code

If you need additional space, please attach an additional file (file 'drag and drop' area provided at the end of this application).

If Employment Experience is included in your resume, please select the "See Resume" button.

Summarize special skills and qualifications acquired from this employment or other experience

If special skills and qualifications are included in your resume, please select the "See Resume" button.

Drag & Drop files here. Remember to select the Upload button before moving on to the next field.

Agreement

I certify that answers given herein are true and complete to the best of my knowledge.

I authorize you to make such investigations and inquiries of my personal, employment, financial or medical history and other related matters as may be necessary in arriving at an employment decision. I hereby release employers, schools or persons from all liability in responding to inquiries in connection with my application.

In the event of employment, I understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the Village.

Signature

Clear

Date

I am unable to sign on the screen. By selecting this button, I acknowledge that I have completed this application.

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