Peer Specialists Limited Job Application

Positions applied for

Referral source: PSL Website EmployeeEmployee's name MediaPlatform

Name

First NameLast Name

Email address

example@example.com

Primary Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

If you are under 18, can you furnish a work

Can you legally work in the U.S.? YesNo (Proof of U.S. citizenship or immigration status will be required upon employment Date

If you are under 18, can you obtain a work permit

Can you legally work in the U.S.?

Please select the date you are available to begin working

Date

If required, will you Travel?

If required, will you work varied hours?

If required, will you Work weekends

If required, will you undergo a pre-employment physical?

If required, will you Provide proof of immunities and freedom from infectious disease?

Do you have a valid Wisconsin Driver's

If, no, do you have a valid driver's license from another state?

Do you own or have access to a car?

Do you have auto insurance?

Educational Background:

1) List last three schools attended last-first. 2) List years completed.3) Degree attained. 4) List majors and minors if applicable

Rows	School and Location	Years Completed	Degree	Major	Minor
School 1
School 2
School 3

Type a question

Rows	Special Courses	Certification
Item 1
Item 2
Item 3

List skills and any other information you would like us to consider

Employment Background

List your last four (4) employers, assignments, field placements, or volunteer activities, starting with the most recent, including military experience. Indicate for each entry the type of activity engaged in. Explain any gaps in employment in the comments section below.

Rows	Employer name	Dates of Employment	Phone number	Your Job title	Summarize the nature of work performed and job responsibilities	Starting and Ending Wage	Immediate Supervisor and Title	Reason for Leaving	NoMay we Contact for a reference
Employer #1
Employer #2
Employer #3
Employer #4

I understand and agree that any misrepresentation or deliberate omission of information by me on this application will be sufficient cause for cancellation of this application and/or immediate termination from PSL if I have been employed regardless of when discovery occurred. Furthermore, I understand and agree that PSL is an employer at will and my employment and benefits can be terminated with or without cause, and with or without notice, at any time, at my option or PSL'. I understand that the continuance of all positions are subject to funding availability and support and at no time is it to be implied that positions are of a permanent nature. I understand that no representative of PSL has the authority to make any assurances to the contrary. I give PSL the right to investigate all references and to secure additional information about me, if job related. I hereby release from liability PSL and/or its representatives for seeking such information and all other persons, corporations or organizations for furnishing such information. PSL is an equal opportunity employer and does not discriminate in employment. No question on this application is used for the purpose of limiting or excluding any applicant's consideration for employment on a basis prohibited by local, state or federal law. This application is current for up to only 60 days and may be kept on file for up to two years.

Applicants signature