CCLS Employment Application
What Location Are You Applying For?
*
Central (Beaver Dam/Juneau)
Corporate (Watertown)
Eastern/Eastern Metro (Waukesha/Milwaukee)
No Central (Wisconsin Rapids/Stevens Point)
No Western (Black River Falls)
So Central (Madison)
So Eastern (Frail Elderly - Bayside/Greenfield/ NewBerlin/Wakesha)
Southern (Janesville/Palmyra/Whitewater)
Western (Onalaska/La Crosse/Viroqua)
Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Availability
Position Applying For
Date Available
-
Month
-
Day
Year
Date
Please Check All That Describe Your Availability:
Full-Time
Part-Time
Weekends (24 Hour Shifts)
1st Shift
2nd Shift
Awake 3rd Shift
Paid Sleep
Live-in/Live-By
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What Other Cities Or Counties Would You Consider Working In Other Than The Area You Are Applying For?
Applicant Information
Are You 18 Years Or Older?
Yes
No
Can You Legally Work In The United Ststes?
Yes
No
How Were You Referred To CCLS?
If Referred By Someone, Please Indicate The Individual's Name
Have You Applied At CCLS Before?
Yes
No
If Yes, When?
-
Month
-
Day
Year
Date
Have You Worked For CCLS Before?
Yes
No
If Yes, When?
-
Month
-
Day
Year
Date
Are You Related To Anyone Employed By CCLS?
Yes
No
If Yes, What Is That Individual's Name?
Do You Have A Valid Drivers License?
Yes
No
If So, What State And License Number?
Do You Have Access To An Insured Reliable Vehicle?
Yes
No
Are You Able To Lift 50LBS With Or Without Reasonable Accommodations?
Yes
No
Back
Next
Save
Employment History & References
List all employment, with your most recent employer first. Be sure to include any time served in the armed forces.
Employer 1
Name Of Employer
*
Dates Of Employment
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Position Held
Reason Left
Beginning And Ending Wage
Supervisor/Contact
May We Contact For A Reference?
*
Yes
No
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Brief Description Of Duties
Employer 2
Name Of Employer
*
Dates Of Employment
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Position Held
Reason Left
Beginning And Ending Wage
Supervisor/Contact
May We Contact For A Reference?
*
Yes
No
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Brief Description Of Duties
Employer 3
Name of Employer
Dates of Employment
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Position Held
Reason Left
Beginning and Ending Wage
Supervisor/Contact
May We Contact for a Referance?
Yes
No
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Brief Description of Duties
Employer 4
Name of Employer
Dates of Employment
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Position Held
Reason Left
Beginning And Ending Wage
Supervisor/Contact
May We Contact For a Reference?
Yes
No
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Brief Description Of Duties
Other References:
List two individuals not related to you or employed by CCLS that you have known for at least one year. (Example: professor, volunteer, clergy, etc.) NOT Co-Workers or friends
Reference 1
Name
*
Phone
*
Email
example@example.com
How Do You Know This Person?
*
Years Known?
*
Reference 2
Name
*
Phone
*
Email
example@example.com
How Do You Know This Person?
*
Years Known?
*
Education
Do You Have A High School Diploma Or GED Equivalent?
Yes
No
Name & Location Of College Or Trade School 1
Graduated?
Yes
No
Year
Degree
Major/Minor
Name & Location Of College Or Trade School 2
Graduated?
Yes
No
Year
Degree
Major/Minor
Back
Next
Save
Certification Record
License Or Certification 1
State & License Number
Certification Status
Active
Expired
License Or Certification 2
State & License Number
Certification Status
Active
Expired
Brief Description Of Certification And/Or Other Skills That Would Relate To The Position You Are Applying For.
Signature
*
Date
*
/
Month
/
Day
Year
Date
Printed Name
*
First Name
Last Name
Print
Save
Continue
Continue
Should be Empty: